Healthcare Provider Details

I. General information

NPI: 1104462613
Provider Name (Legal Business Name): MARIA GUADALUPE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 W SOUTHERN AVE
TEMPE AZ
85282-4519
US

IV. Provider business mailing address

1533 E WILLETTA ST
PHOENIX AZ
85006-2935
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-3999
  • Fax: 602-569-3887
Mailing address:
  • Phone: 602-715-2840
  • Fax: 602-569-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number234160
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: