MEDICARE: MARY RENEE GOLDEN DNP

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	363LP0200X	Pediatric Nurse Practitioner	AP10182	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487182648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY RENEE GOLDEN DNP

Provider Business Mailing Address
First Line	:	1739 E BEVERLY AVE STE 204
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3593
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2202 N STOCKTON HILL RD STE 100
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4622
Country	:	US
Telephone Number	:	928-681-8706
Fax Number	:	928-681-8707

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

Provider Enumeration Date	:	05/31/2017
Last Update Date	:	01/04/2022

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