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General NPI Number Information
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NPI Number | 1447222328
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Entity Type | Individual
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Provider Name | JACQUELINE LEA AGENBROAD NP
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Gender | Female
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Dates
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Enumeration Date | 02/03/2006
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Last Update Date | 06/12/2008
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Provider Practice Location Address
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Address Line | 1300 N 12TH ST SUITE 407
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City | PHOENIX
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State | AZ
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Zip | 85006-2848
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Country | US
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Telephone | 602-239-6762
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Fax | 602-239-5112
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Provider Business Mailing Address
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Address Line | 12895 W PASADENA AVE
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340
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Country | US
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Telephone | 623-935-2373
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Fax | 623-932-4558
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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 | RN097748
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | NP290
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License Number State | AZ
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