Healthcare Provider Details

I. General information

NPI: 1578280376
Provider Name (Legal Business Name): EMILY ANNE BENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 W THOMAS RD STE 155
PHOENIX AZ
85037-3360
US

IV. Provider business mailing address

9020 W LONE CACTUS DR
PEORIA AZ
85382-2469
US

V. Phone/Fax

Practice location:
  • Phone: 480-573-7922
  • Fax:
Mailing address:
  • Phone: 480-578-1867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number300203
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN199542
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: