MEDICARE: MARIA INGALLA 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	163W00000X	Registered Nurse	RN2306603	MA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP10355	AZ

General Provider Information

NPI Number	:	1972040921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA INGALLA PMHNP-BC

Provider Business Mailing Address
First Line	:	1515 E MISSOURI AVE
Second Line	:	SUITE 201
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2446
Country	:	US
Telephone Number	:	602-234-3733
Fax Number	:

Provider Business Practice Location Address
First Line	:	7910 W THOMAS RD
Second Line	:	SUITE 112
City	:	PHOENIX
State	:	AZ
Zip	:	85033-4830
Country	:	US
Telephone Number	:	623-414-4325
Fax Number	:

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

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	07/15/2021

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