Healthcare Provider Details

I. General information

NPI: 1962628271
Provider Name (Legal Business Name): ELAINE MARIE NEW MOON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 N CENTRAL AVE STE 130 WILCOX SUMMER HAWK RANCH
PHOENIX AZ
85012-1804
US

IV. Provider business mailing address

4520 N CENTRAL #130 WILCOX SUMMER HAWK RANCH
PHOENIX AZ
85012
US

V. Phone/Fax

Practice location:
  • Phone: 602-424-1600
  • Fax: 602-532-7202
Mailing address:
  • Phone: 602-424-1600
  • Fax: 602-532-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN064934
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: