MEDICARE: INIOBONG KOFFI PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	265764	AZ
2	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	265764	AZ

General Provider Information

NPI Number	:	1285597617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INIOBONG KOFFI PMHNP-BC

Provider Business Mailing Address
First Line	:	2619 E PIERCE ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85008-6092
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2619 E PIERCE ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85008-6092
Country	:	US
Telephone Number	:	480-344-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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