Provider Demographics
NPI:1285030429
Name:TRUJILLO, JOHANA HAYDEE (CLINICIAN ASSOCIATE)
Entity Type:Individual
Prefix:
First Name:JOHANA
Middle Name:HAYDEE
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:CLINICIAN ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-599-5404
Mailing Address - Fax:602-599-5704
Practice Address - Street 1:619 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5004
Practice Address - Country:US
Practice Address - Phone:602-808-2828
Practice Address - Fax:480-649-5214
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator