Healthcare Provider Details

I. General information

NPI: 1548657802
Provider Name (Legal Business Name): WILLIE BENJAMIN BALLOU NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 S MCCLINTOCK DR
TEMPE AZ
85282-5879
US

IV. Provider business mailing address

4041 S MCCLINTOCK DR STE 311
TEMPE AZ
85282-5879
US

V. Phone/Fax

Practice location:
  • Phone: 520-233-7111
  • Fax:
Mailing address:
  • Phone: 520-233-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number229136
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP127755
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: