1790536654 NPI number — ADVANCED PRACTICE NURSE SOURCE, LLC

Table of content: (NPI 1790536654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790536654 NPI number — ADVANCED PRACTICE NURSE SOURCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PRACTICE NURSE SOURCE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790536654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5830 W THUNDERBIRD RD STE B8118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85306-4654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12772 N 58TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85304-1878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-550-6059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SARHAN
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
ANN MILLER
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
801-550-6059

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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