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General NPI Number Information
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NPI Number | 1285229534
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Entity Type | Individual
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Provider Name | JISMI THEEYATTUVELI NP
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Gender | Female
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Dates
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Enumeration Date | 03/08/2021
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Last Update Date | 11/14/2022
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Provider Practice Location Address
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Address Line | 51 S 48TH ST
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City | MESA
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State | AZ
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Zip | 85206-1250
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Country | US
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Telephone | 480-832-8333
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Fax |
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Provider Business Mailing Address
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Address Line | 4291 E LEXINGTON AVE
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City | GILBERT
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State | AZ
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Zip | 85234-0729
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Country | US
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Telephone | 480-310-8524
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 254316
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 138064
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License Number State | AZ
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