Healthcare Provider Details

I. General information

NPI: 1871763888
Provider Name (Legal Business Name): DOMTILLAH CHEPCHIRCHIR PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 E OAK ST
PHOENIX AZ
85008-2410
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 400
PHOENIX AZ
85012-2929
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-808-2799
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number281897
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: