Healthcare Provider Details

I. General information

NPI: 1417501867
Provider Name (Legal Business Name): JEANMARIE EVANGELINE MEAD RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 CAMPBELL AVE
PRESCOTT AZ
86301-1211
US

IV. Provider business mailing address

300 E GURLEY ST
PRESCOTT AZ
86301-3823
US

V. Phone/Fax

Practice location:
  • Phone: 928-717-3276
  • Fax: 928-717-3275
Mailing address:
  • Phone: 928-445-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN052064
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: