Provider Demographics
NPI:1306046982
Name:CLANCY, MARILYNNE (RN, MS, PNP)
Entity type:Individual
Prefix:MS
First Name:MARILYNNE
Middle Name:
Last Name:CLANCY
Suffix:
Gender:F
Credentials:RN, MS, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 E HARMONT DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3864
Mailing Address - Country:US
Mailing Address - Phone:602-331-1470
Mailing Address - Fax:602-678-5803
Practice Address - Street 1:1235 E HARMONT DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3864
Practice Address - Country:US
Practice Address - Phone:602-331-1470
Practice Address - Fax:602-678-5803
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16022426163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ851924OtherAHCCCS