Basic Information
Provider Information | |||||||||
NPI: | 1295802957 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RADFORD | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, NPP, M.SC(A) | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOUDARRES | ||||||||
OtherFirstName: | DEBORAH | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN, NPP, M.SC(A) | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3707 N STOCKTON HILL RD STE B | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864090507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287578111 | ||||||||
FaxNumber: | 9287573256 | ||||||||
Practice Location | |||||||||
Address1: | 1741 SYCAMORE AVE | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864090927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287578111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 533841 | NY | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LF0000X | RN184531 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | F400881 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP5484 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 900068 | 05 | AZ |   | MEDICAID |