Provider Demographics
NPI:1215580469
Name:JOSEFCHUK, RACHEL BONVILLAIN (PMHNP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:BONVILLAIN
Last Name:JOSEFCHUK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 N MONTE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1940
Mailing Address - Country:US
Mailing Address - Phone:928-707-1851
Mailing Address - Fax:
Practice Address - Street 1:1515 E CEDAR AVE STE B-4
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1645
Practice Address - Country:US
Practice Address - Phone:928-779-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ229134363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ556723Medicaid
AZZ245748OtherMEDICARE