Healthcare Provider Details

I. General information

NPI: 1952267775
Provider Name (Legal Business Name): KWESI IMMANUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 E CAMELBACK RD # 2412
PHOENIX AZ
85016-4502
US

IV. Provider business mailing address

3104 E CAMELBACK RD # 2412
PHOENIX AZ
85016-4502
US

V. Phone/Fax

Practice location:
  • Phone: 520-371-0846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number254947
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: