1578942165 NPI number — JODI MARIE PALMER FNP

Table of content: JODI MARIE PALMER FNP (NPI 1578942165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578942165 NPI number — JODI MARIE PALMER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALMER
Provider First Name:
JODI
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

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:
1578942165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W UTOPIA RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-434-6200
Provider Business Mailing Address Fax Number:
623-434-6164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3648 W ANTHEM WAY
Provider Second Line Business Practice Location Address:
BLDG. A-100,
Provider Business Practice Location Address City Name:
ANTHEM
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85086-7001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-434-6444
Provider Business Practice Location Address Fax Number:
623-434-6448
Provider Enumeration Date:
05/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  AP7676 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: F0215444 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Z25025 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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