Provider Demographics
NPI:1992305551
Name:OBAHIAGBON, ALZETTA CLAY
Entity type:Individual
Prefix:
First Name:ALZETTA
Middle Name:CLAY
Last Name:OBAHIAGBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1612
Mailing Address - Country:US
Mailing Address - Phone:480-557-0970
Mailing Address - Fax:
Practice Address - Street 1:1750 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1612
Practice Address - Country:US
Practice Address - Phone:480-557-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN195688163W00000X
AZ255362363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse