Provider Demographics
NPI:1063492056
Name:DUNIVANT, KAREN RENEE (CPNP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:RENEE
Last Name:DUNIVANT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:RENEE
Other - Last Name:DOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:1920 E. CAMBRIDGE AVE
Mailing Address - Street 2:# 302
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-279-1697
Mailing Address - Fax:602-264-0461
Practice Address - Street 1:1920 E. CAMBRIDGE AVE
Practice Address - Street 2:# 302
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-279-1697
Practice Address - Fax:602-264-0461
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1995363L00000X
AZ20080169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ897598Medicaid