Provider Demographics
NPI:1104103746
Name:GARIBALDI, BETTY RAE (LPN)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:RAE
Last Name:GARIBALDI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1817
Mailing Address - Country:US
Mailing Address - Phone:602-764-0834
Mailing Address - Fax:602-271-2963
Practice Address - Street 1:2920 N 34TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-5250
Practice Address - Country:US
Practice Address - Phone:602-764-0834
Practice Address - Fax:602-271-2963
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP15879390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program