Provider Demographics
NPI:1306859798
Name:BURCHAM, CAROLYN VERNEZ (NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:VERNEZ
Last Name:BURCHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:8836 N 23RD AVE
Practice Address - Street 2:B1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4185
Practice Address - Country:US
Practice Address - Phone:602-944-9810
Practice Address - Fax:602-216-7040
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664148363LF0000X, 363LP0808X
AZAP8440363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117941Medicaid
AZ117941Medicaid