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General NPI Number Information
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NPI Number | 1477153823
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Entity Type | Individual
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Provider Name | MARY BALDERSTON
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Gender | Female
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Dates
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Enumeration Date | 10/27/2020
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 901 W REX ALLEN DR
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City | WILLCOX
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State | AZ
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Zip | 85643-1009
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Country | US
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Telephone | 520-384-3541
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Fax |
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Provider Business Mailing Address
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Address Line | 15650 E SONORAN PEAK TRL
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City | VAIL
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State | AZ
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Zip | 85641-8913
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Country | US
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Telephone | 928-607-4681
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN158380
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License Number State | AZ
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