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General NPI Number Information
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NPI Number | 1265958755
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Entity Type | Organization
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Legal Business Name | PRESCOTT FAMILY PRACTICE AND WELLNESS, LLC
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Dates
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Enumeration Date | 08/16/2017
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Last Update Date | 08/30/2017
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Provider Practice Location Address
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Address Line | 1151 W IRON SPRINGS RD STE F
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City | PRESCOTT
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State | AZ
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Zip | 86305-1614
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Country | US
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Telephone | 928-533-1136
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Fax |
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Provider Business Mailing Address
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Address Line | 608 VISTA DEL CERRO ST
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City | PRESCOTT
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State | AZ
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Zip | 86301-1059
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Country | US
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Telephone | 480-729-4939
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. STEPHANIE DIANE TEN EYCK
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Credential | NP
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Telephone | 480-729-4939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP7670
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License Number State | AZ
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