Healthcare Provider Details

I. General information

NPI: 1184259962
Provider Name (Legal Business Name): CHARLANN CARROLL STAAB CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10133 N 92ND ST STE 102
SCOTTSDALE AZ
85258-4556
US

IV. Provider business mailing address

1146 N MELODY CIR
CHANDLER AZ
85225-1695
US

V. Phone/Fax

Practice location:
  • Phone: 480-644-6416
  • Fax:
Mailing address:
  • Phone: 480-797-9653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number220405
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number220405
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number220405
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number220405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: