Healthcare Provider Details

I. General information

NPI: 1295227155
Provider Name (Legal Business Name): JESSICA DENISSE PORTILLOS DNP-CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E VAN BUREN ST
PHOENIX AZ
85006-3742
US

IV. Provider business mailing address

480 S PARKCREST ST
GILBERT AZ
85296-9517
US

V. Phone/Fax

Practice location:
  • Phone: 602-251-8359
  • Fax:
Mailing address:
  • Phone: 480-385-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1524
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: