Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 95649 | AZ |
NPI | 1063438828 |
---|---|
Provider Name | Tracey Gillispie |
First Address | Phoenix, AZ 85013-3420 |
Second Address | Phoenix, AZ 85013-3420 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
703406 | (05) | AZ |