Healthcare Provider Details

I. General information

NPI: 1972040921
Provider Name (Legal Business Name): MARIA INGALLA PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W THOMAS RD SUITE 112
PHOENIX AZ
85033-4830
US

IV. Provider business mailing address

1515 E MISSOURI AVE SUITE 201
PHOENIX AZ
85014-2446
US

V. Phone/Fax

Practice location:
  • Phone: 623-414-4325
  • Fax:
Mailing address:
  • Phone: 602-234-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP10355
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2306603
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: