Healthcare Provider Details

I. General information

NPI: 1174186670
Provider Name (Legal Business Name): SAMANTHA SHOLEH WILLEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA SHOLEH KORDEIE

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 W ROYAL PALM RD
PHOENIX AZ
85021-4916
US

IV. Provider business mailing address

7770 N PLACITA SIN MENTIRAS
TUCSON AZ
85718-1286
US

V. Phone/Fax

Practice location:
  • Phone: 602-353-2340
  • Fax:
Mailing address:
  • Phone: 503-334-6481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number225016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: