Basic Information
Provider Information | |||||||||
NPI: | 1962905612 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALZANO | ||||||||
FirstName: | CATHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3815 E BELL RD STE 2200 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850322139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026333838 | ||||||||
FaxNumber: | 6026333845 | ||||||||
Practice Location | |||||||||
Address1: | 13555 W MCDOWELL RD STE 103 | ||||||||
Address2: |   | ||||||||
City: | GOODYEAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 853952625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239321157 | ||||||||
FaxNumber: | 6239321045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2018 | ||||||||
LastUpdateDate: | 12/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/24/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 086499 | AZ | N | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 223221 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 521142 | 05 | AZ |   | MEDICAID | Z227298 | 01 | AZ | MEDICARE | OTHER |