Basic Information
| Provider Information | |||||||||
| NPI: | 1962753343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETZMAN | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGOLDRICK | ||||||||
| OtherFirstName: | HALEY | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2120 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029336100 | ||||||||
| FaxNumber: | 6029332422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 60220812 | WA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP8306 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.