Basic Information
| Provider Information | |||||||||
| NPI: | 1992433874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVARES | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2406 | ||||||||
| Address2: | |||||||||
| City: | CLAYPOOL | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855322406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9289610159 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 MEDICINE WAY RD | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN105209 | AZ | N | Nursing Service Providers | Registered Nurse | 363LP2300X | 279367 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.