Provider Demographics
NPI:1699742866
Name:RICKMAN, MARY (ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RICKMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98819
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193
Mailing Address - Country:US
Mailing Address - Phone:602-494-3659
Mailing Address - Fax:602-494-3682
Practice Address - Street 1:3805 E BELL RD
Practice Address - Street 2:SUITE 3100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2136
Practice Address - Country:US
Practice Address - Phone:602-867-8644
Practice Address - Fax:602-795-5698
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN053459363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ187394Medicaid
AZ187394Medicaid
AZ114600Medicare PIN