Basic Information
| Provider Information | |||||||||
| NPI: | 1598986739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING-DAGEN | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18404 N TATUM BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850321510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029921900 | ||||||||
| FaxNumber: | 6024857440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234346200 | ||||||||
| FaxNumber: | 6024346164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP3336 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN178591 | AZ | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 743768 | 05 | AZ | MEDICAID |