Healthcare Provider Details

I. General information

NPI: 1063024909
Provider Name (Legal Business Name): KIMBERLY DAWN YAZZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 N CENTRAL AVE BLDG C
PHOENIX AZ
85012-3313
US

IV. Provider business mailing address

12910 W SOLEDAD ST
EL MIRAGE AZ
85335-5375
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-5262
  • Fax:
Mailing address:
  • Phone: 602-354-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number313755
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN165975
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: