Basic Information
| Provider Information | |||||||||
| NPI: | 1477153823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALDERSTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BRANDSTROM | ||||||||
| OtherFirstName: | MARY | ||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15650 E SONORAN PEAK TRL | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856418913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286074681 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 W REX ALLEN DR | ||||||||
| Address2: | |||||||||
| City: | WILLCOX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856431009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203843541 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN158380 | AZ | Y | Nursing Service Providers | Registered Nurse |
No ID Information.