Basic Information
| Provider Information | |||||||||
| NPI: | 1033622295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAMBETH | ||||||||
| FirstName: | KIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9250 N 3RD ST STE 4010 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202432 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10815 W MCDOWELL RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853925016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239363312 | ||||||||
| FaxNumber: | 6239364248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2017 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP10679 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 331053 | 05 | AZ | MEDICAID | Z209239 | 01 | AZ | MEDICARE | OTHER |