Provider Demographics
NPI:1366819401
Name:VILLARREAL, MEREDITH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 N CENTRAL AVE
Mailing Address - Street 2:#2057
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1830
Mailing Address - Country:US
Mailing Address - Phone:623-330-8388
Mailing Address - Fax:
Practice Address - Street 1:5048 W NORTHERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1558
Practice Address - Country:US
Practice Address - Phone:623-435-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily