Provider Demographics
NPI:1962143669
Name:MENJIVAR, DAISY
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAISY
Other - Middle Name:
Other - Last Name:MENJIVAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19918 N 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7088
Mailing Address - Country:US
Mailing Address - Phone:480-806-9877
Mailing Address - Fax:
Practice Address - Street 1:19918 N 65TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7088
Practice Address - Country:US
Practice Address - Phone:480-806-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10812H376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881159309Medicaid