Healthcare Provider Details

I. General information

NPI: 1265346639
Provider Name (Legal Business Name): MR. FELIX MBENDA DISSO SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E VAN BUREN ST
PHOENIX AZ
85008-6037
US

IV. Provider business mailing address

3441 S 77TH LN
PHOENIX AZ
85043-1258
US

V. Phone/Fax

Practice location:
  • Phone: 602-403-2969
  • Fax:
Mailing address:
  • Phone: 602-403-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number290708
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: