Provider Demographics
NPI:1063789568
Name:NEBLETT, MANDY (FNP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:NEBLETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 N 19TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2451
Mailing Address - Country:US
Mailing Address - Phone:602-589-0500
Mailing Address - Fax:602-314-4552
Practice Address - Street 1:5501 N 19TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2451
Practice Address - Country:US
Practice Address - Phone:602-589-0500
Practice Address - Fax:602-314-4552
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZFNP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ676890Medicaid