Healthcare Provider Details

I. General information

NPI: 1700113487
Provider Name (Legal Business Name): NELIDA FRUCTUOZO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15802 N PARKVIEW PL
SURPRISE AZ
85374-7466
US

IV. Provider business mailing address

15802 N PARKVIEW PL
SURPRISE AZ
85374-7466
US

V. Phone/Fax

Practice location:
  • Phone: 623-523-8004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN145557
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: