Provider Demographics
NPI:1992433874
Name:TAVARES, KATHERINE ELAINE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELAINE
Last Name:TAVARES
Suffix:
Gender:F
Credentials:FNP-BC
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 2406
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85532-2406
Mailing Address - Country:US
Mailing Address - Phone:928-961-0159
Mailing Address - Fax:
Practice Address - Street 1:103 MEDICINE WAY RD
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542-5000
Practice Address - Country:US
Practice Address - Phone:928-475-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN105209163W00000X
AZ279367363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse