MEDICARE: DENISE M WILLARD FNP

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	RN063492	AZ

General Provider Information

NPI Number	:	1740266915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE M WILLARD FNP

Provider Business Mailing Address
First Line	:	3144 N 78TH ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-1264
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 N 3RD ST
Second Line	:	SUITE 170
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1471
Country	:	US
Telephone Number	:	602-462-1132
Fax Number	:

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

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	05/23/2012

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