Healthcare Provider Details

I. General information

NPI: 1821235722
Provider Name (Legal Business Name): CONNIE M. MESTETH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 160 & NAVAJO ROUTE 25 - RED MESA
TEECNOSPOS AZ
86514
US

IV. Provider business mailing address

HCR 6100 BOX 30
TEECNOSPOS AZ
86514
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax: 928-656-5164
Mailing address:
  • Phone: 928-656-5000
  • Fax: 928-656-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR022332
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: