=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831028448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D.G FAMILY CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2026
-----------------------------------------------------
Last Update Date | 05/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11242 N 19TH AVE STE 21
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-707-2798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4821 N 108TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85037-5471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-707-2798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DESIRE NTAJONJORA NKOMEZI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-707-2798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------