Provider Demographics
NPI:1366015067
Name:BALAN, PRIYA SABUMON (RN)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:SABUMON
Last Name:BALAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:STE I164
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3762
Mailing Address - Country:US
Mailing Address - Phone:623-878-2100
Mailing Address - Fax:
Practice Address - Street 1:4112 E WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8848
Practice Address - Country:US
Practice Address - Phone:302-241-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ271815363LP0808X
AZRN214133163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty