Healthcare Provider Details

I. General information

NPI: 1174027601
Provider Name (Legal Business Name): SIDONIE B JUSTYNSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SIDONIE BEATRICE NGANKEU

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1394 W 16TH ST
YUMA AZ
85364-4430
US

IV. Provider business mailing address

2407 CLEAR CREEK RD
KILLEEN TX
76549-5721
US

V. Phone/Fax

Practice location:
  • Phone: 928-770-2053
  • Fax: 928-298-6946
Mailing address:
  • Phone: 254-519-8803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024191050
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11179
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP136386
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: