Healthcare Provider Details

I. General information

NPI: 1376257170
Provider Name (Legal Business Name): MARCUS NIELSON PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 E CAMELBACK RD STE 625
PHOENIX AZ
85016-3458
US

IV. Provider business mailing address

2355 E CAMELBACK RD STE 625
PHOENIX AZ
85016-3458
US

V. Phone/Fax

Practice location:
  • Phone: 480-581-8536
  • Fax:
Mailing address:
  • Phone: 480-710-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number301764
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN168434
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: