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General NPI Number Information
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NPI Number | 1467182774
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Entity Type | Organization
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Legal Business Name | IDEAL SELF LLC
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Dates
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Enumeration Date | 06/10/2022
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Last Update Date | 03/19/2023
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Provider Practice Location Address
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Address Line | 12620 N CAVE CREEK RD STE 10A
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City | PHOENIX
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State | AZ
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Zip | 85022-6528
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Country | US
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Telephone | 623-303-6777
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Fax |
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Provider Business Mailing Address
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Address Line | 12620 N CAVE CREEK RD STE 10A
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City | PHOENIX
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State | AZ
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Zip | 85022-6528
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Country | US
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Telephone | 623-303-6777
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | ANGELA CHILDS
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Credential | FNP, PMHNP
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Telephone | 623-303-6777
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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