Provider Demographics
NPI:1386228658
Name:REALE, JENNIFER RENAE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENAE
Last Name:REALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENAE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18614 N 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4408
Mailing Address - Country:US
Mailing Address - Phone:720-988-0022
Mailing Address - Fax:
Practice Address - Street 1:1835 W MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3046
Practice Address - Country:US
Practice Address - Phone:602-230-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily