Provider Demographics
NPI:1104097070
Name:POULSON, MARIA LYN C (DC)
Entity type:Individual
Prefix:
First Name:MARIA LYN
Middle Name:C
Last Name:POULSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 E BELL RD STE 140
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2937
Mailing Address - Country:US
Mailing Address - Phone:602-788-3159
Mailing Address - Fax:602-788-0501
Practice Address - Street 1:2040 E BELL RD STE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2937
Practice Address - Country:US
Practice Address - Phone:602-788-3159
Practice Address - Fax:602-788-0501
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor