Provider Demographics
NPI:1962753343
Name:DIETZMAN, HALEY M
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:M
Last Name:DIETZMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:A
Other - Last Name:MCGOLDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:2120 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004
Practice Address - Country:US
Practice Address - Phone:602-933-6100
Practice Address - Fax:602-933-2422
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN 60220812163W00000X
AZAP8306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse