Basic Information
| Provider Information | |||||||||
| NPI: | 1144644287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSIEU | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WELSH | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12075 E STATE ROUTE 69 | ||||||||
| Address2: | |||||||||
| City: | DEWEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863274517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287721673 | ||||||||
| FaxNumber: | 6022184443 | ||||||||
| Practice Location | |||||||||
| Address1: | 12075 E STATE ROUTE 69 | ||||||||
| Address2: | |||||||||
| City: | DEWEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863274517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287779600 | ||||||||
| FaxNumber: | 6022184443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP2936392 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 226377 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.