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General NPI Number Information
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NPI Number | 1417469669
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Entity Type | Organization
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Legal Business Name | TIBA CARE PLLC
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Dates
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Enumeration Date | 10/27/2017
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Last Update Date | 10/27/2017
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Provider Practice Location Address
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Address Line | 315 W ELLIOT RD STE 107-167
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City | TEMPE
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State | AZ
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Zip | 85284-1328
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Country | US
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Telephone | 623-226-8105
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Fax |
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Provider Business Mailing Address
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Address Line | 5810 S 35TH PL
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City | PHOENIX
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State | AZ
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Zip | 85040-2844
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Country | US
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Telephone | 314-757-8291
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | JENNIFER GRESHAM
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Credential | FNP-C
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Telephone | 623-226-8105
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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 | AP8433
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License Number State | AZ
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