Basic Information
Provider Information | |||||||||
NPI: | 1104933670 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VOGT-ROBERTS | ||||||||
FirstName: | MARLA | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROBERTS | ||||||||
OtherFirstName: | MARLA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3030 N CENTRAL AVE #1001 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850123322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024064786 | ||||||||
FaxNumber: | 4808892638 | ||||||||
Practice Location | |||||||||
Address1: | 500 W THOMAS RD # 720730 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850134224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024063715 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 02/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | RN106344 | AZ | N |   | Other Service Providers | Midwife |   | 367A00000X | AP7046 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 479130 | 05 | AZ |   | MEDICAID | 4704123693 | 01 | MI | RN | OTHER | 4704123693 | 01 | MI | NURSE MIDWIFE SPECIALTY | OTHER | MV3528710 | 01 |   | DEA | OTHER | RN106344 | 01 | AZ | RN | OTHER | 7049 | 01 | AZ | CNM | OTHER |