Healthcare Provider Details

I. General information

NPI: 1457044653
Provider Name (Legal Business Name): MARY ANN MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E MITCHELL DR
PHOENIX AZ
85012-2330
US

IV. Provider business mailing address

202 E EARLL DR STE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-4331
  • Fax: 602-264-4095
Mailing address:
  • Phone: 602-808-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number292594
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: