Healthcare Provider Details

I. General information

NPI: 1972186138
Provider Name (Legal Business Name): KANDY LIZZETH MEDINA PEREZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KANDY LIZZETH MEDINA PEREZ

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13755 N LITCHFIELD RD STE 105
SURPRISE AZ
85379-4288
US

IV. Provider business mailing address

7908 N COTTON LN
WADDELL AZ
85355-9751
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-7404
  • Fax: 949-437-2917
Mailing address:
  • Phone: 623-512-8308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRNP267355
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN211082
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: