MEDICARE: SUSAN KERUBO NYAENYA PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	PMH10240083	AZ

General Provider Information

NPI Number	:	1982420030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KERUBO NYAENYA PMHNP

Provider Business Mailing Address
First Line	:	1030 S DOBSON RD
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-2916
Country	:	US
Telephone Number	:	480-321-5348
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 N 68TH ST
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85257-1202
Country	:	US
Telephone Number	:	623-462-2803
Fax Number	:

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

Provider Enumeration Date	:	11/22/2024
Last Update Date	:	11/22/2024

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