Provider Demographics
NPI:1164478699
Name:BOZZOLO, DONNA LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LOUISE
Last Name:BOZZOLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S WILLARD ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6743
Mailing Address - Country:US
Mailing Address - Phone:928-634-2574
Mailing Address - Fax:928-634-2841
Practice Address - Street 1:450 S WILLARD ST
Practice Address - Street 2:SUITE 120
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6743
Practice Address - Country:US
Practice Address - Phone:928-634-2574
Practice Address - Fax:928-634-2841
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1994363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ941759Medicaid
S69382Medicare UPIN
AZ941759Medicaid