Basic Information
| Provider Information | |||||||||
| NPI: | 1134523624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENTFROW | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | DOMINIQUE HART | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HART | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
| OtherMiddleName: | DOMINIQUE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1260 S CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856140504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204075600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18857 S LA CANADA DR | ||||||||
| Address2: | |||||||||
| City: | SAHUARITA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856297990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204075800 | ||||||||
| FaxNumber: | 5204075990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2014 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP7353 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 985949 | 05 | AZ | MEDICAID |