Healthcare Provider Details

I. General information

NPI: 1902304678
Provider Name (Legal Business Name): BETH PEMBROKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16620 N 40TH ST STE E-1
PHOENIX AZ
85032-3348
US

IV. Provider business mailing address

4531 N 16TH ST STE 114
PHOENIX AZ
85016-5344
US

V. Phone/Fax

Practice location:
  • Phone: 602-464-9576
  • Fax: 602-626-8901
Mailing address:
  • Phone: 602-464-9576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13987096-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0102379-C-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number79497
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF405679-01
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number271416
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: