Basic Information
| Provider Information | |||||||||
| NPI: | 1669672697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANZOEILLO | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2702 N 3RD ST STE 4020 | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850044608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233492 | ||||||||
| FaxNumber: | 6023233399 | ||||||||
| Practice Location | |||||||||
| Address1: | 4315 N MARYVALE PKWY | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 6236911770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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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 | 363LP0200X | AP2462 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 11774490 | 01 | AZ | CAQH | OTHER | 230765 | 05 | AZ | MEDICAID |