Healthcare Provider Details

I. General information

NPI: 1740266915
Provider Name (Legal Business Name): DENISE M WILLARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 N 3RD ST SUITE 170
PHOENIX AZ
85004-1471
US

IV. Provider business mailing address

3144 N 78TH ST
MESA AZ
85207-1264
US

V. Phone/Fax

Practice location:
  • Phone: 602-462-1132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN063492
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: