=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942015755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUREBALANCE HEALTHCARE SERVICE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 238 S 165TH DR
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-551-6636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1846 E INNOVATION PARK DR STE 100
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP
-----------------------------------------------------
Name | TERRIANNE DONER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-551-6636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------