=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265122584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIANET LANTIGUA PONCE DE LEON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2023
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10645 N 43RD AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-233-2006
-----------------------------------------------------
Fax | 602-314-6115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10645 N 43RD AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-233-2006
-----------------------------------------------------
Fax | 602-314-6115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F05230008
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN305992
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------