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General NPI Number Information
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NPI Number | 1205397288
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Entity Type | Individual
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Provider Name | ELIZABETH KATHLEEN FOX-MTANDIKA
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Gender | Female
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Dates
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Enumeration Date | 03/30/2019
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Last Update Date | 02/20/2023
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Provider Practice Location Address
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Address Line | 37100 N GANTZEL RD STE 201
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85140-7352
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Country | US
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Telephone | 480-394-4469
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Fax |
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Provider Business Mailing Address
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Address Line | 4760 E BASELINE RD APT 2025
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City | MESA
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State | AZ
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Zip | 85206-4688
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Country | US
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Telephone | 602-359-7866
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 009452
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License Number State | AZ
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