Healthcare Provider Details

I. General information

NPI: 1639384886
Provider Name (Legal Business Name): NOLA JEAN NAHA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 264 MILE MARKER 388
POLACCA AZ
86042-4000
US

IV. Provider business mailing address

PO BOX 4000 HWY 264 MILE MARKER 388
POLACCA AZ
86042-4000
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6260
  • Fax: 928-737-6001
Mailing address:
  • Phone: 928-737-6260
  • Fax: 928-737-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License NumberRN069234
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: