=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114643343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRAME HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2022
-----------------------------------------------------
Last Update Date | 10/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10320 W MCDOWELL RD STE 5015
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-980-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10320 W MCDOWELL RD STE 5015
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-980-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | JACQUELINE GUZMAN
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 623-980-2150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------