MEDICARE: SHALISSA MARIE EASLEY FNP-C

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	287086	AZ

General Provider Information

NPI Number	:	1982303368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALISSA MARIE EASLEY FNP-C

Provider Business Mailing Address
First Line	:	3201 W PEORIA AVE STE C500
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4600
Country	:	US
Telephone Number	:	623-773-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 W PEORIA AVE STE C500
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4600
Country	:	US
Telephone Number	:	623-773-2000
Fax Number	:

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

Provider Enumeration Date	:	02/24/2023
Last Update Date	:	05/15/2023

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