Healthcare Provider Details

I. General information

NPI: 1346086501
Provider Name (Legal Business Name): GATEWAY HEALTH WELLNESS AND AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 S MCCLINTOCK DR STE A&B
TEMPE AZ
85283-3266
US

IV. Provider business mailing address

7512 E CLINTON ST
SCOTTSDALE AZ
85260-6446
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-6253
  • Fax:
Mailing address:
  • Phone: 973-731-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PANSY M HARRIS-LANE
Title or Position: OWNER/PROVIDER
Credential: NP
Phone: 973-731-6253