Healthcare Provider Details

I. General information

NPI: 1528895182
Provider Name (Legal Business Name): GINNO DE LEON PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N PRIEST DR # 109
TEMPE AZ
85288-1213
US

IV. Provider business mailing address

14894 W VALENTINE ST
SURPRISE AZ
85379-4277
US

V. Phone/Fax

Practice location:
  • Phone: 702-589-4871
  • Fax:
Mailing address:
  • Phone: 480-278-5842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number314334
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: