MEDICARE: LIFEOAK MENTAL HEALTH PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1164103594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEOAK MENTAL HEALTH PLLC

Provider Business Mailing Address
First Line	:	3707 E SOUTHERN AVE STE 1018
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-6201
Country	:	US
Telephone Number	:	602-878-7702
Fax Number	:	602-878-7702

Provider Business Practice Location Address
First Line	:	3707 E SOUTHERN AVE STE 1018
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-6201
Country	:	US
Telephone Number	:	602-878-7702
Fax Number	:	602-878-7702

Authorized Official
Title or Position	:	OWNER
Name	:	RUNAKO RICHARDSON
Credential	:	NP
Telephone Number	:	214-693-5746

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	07/27/2023

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