Healthcare Provider Details

I. General information

NPI: 1548012966
Provider Name (Legal Business Name): PONDEROSA PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 W BASELINE RD # 182-8355
PHOENIX AZ
85041-6574
US

IV. Provider business mailing address

2030 W BASELINE RD # 182-8355
PHOENIX AZ
85041-6574
US

V. Phone/Fax

Practice location:
  • Phone: 928-235-2927
  • Fax: 928-268-0289
Mailing address:
  • Phone: 928-235-2927
  • Fax: 928-268-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CAMEO E JOHNSON
Title or Position: OWNER
Credential: PMHNP
Phone: 928-235-2927