Healthcare Provider Details

I. General information

NPI: 1235304031
Provider Name (Legal Business Name): SIDDIQUI ROSE HERNANDEZ CRNP PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSEMARY LEIGH COLLINS-SIMPSON CRNP PMHNP-BC

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E BASELINE RD STE D104
TEMPE AZ
85283-1291
US

IV. Provider business mailing address

PO BOX 17779
PHOENIX AZ
85011-0779
US

V. Phone/Fax

Practice location:
  • Phone: 480-718-0568
  • Fax:
Mailing address:
  • Phone: 480-718-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN213648
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2010039446
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR205786
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11103
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: