MEDICARE: MARIA VIDALE

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN199848	AZ

General Provider Information

NPI Number	:	1336831502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA VIDALE

Provider Business Mailing Address
First Line	:	230 W KINGS AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7502
Country	:	US
Telephone Number	:	480-242-3428
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 W KINGS AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7502
Country	:	US
Telephone Number	:	480-242-3428
Fax Number	:

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

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	05/24/2023

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Directions to “ MARIA VIDALE ” Practice Location

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