=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922638055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS HEALTH ARIZONA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2020
-----------------------------------------------------
Last Update Date | 01/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 E SOUTHERN AVE STE I3
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-957-0540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3545 W MAUNA LOA LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85053-4653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-957-0540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, CEO
-----------------------------------------------------
Name | MISS DONISHA DAWN PARDUE
-----------------------------------------------------
Credential | FNP-BC, PMHNP-BC
-----------------------------------------------------
Telephone | 603-957-0540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------