Provider Demographics
NPI:1407994809
Name:MASSIMO, ANNMARIE (OGNP)
Entity Type:Individual
Prefix:MS
First Name:ANNMARIE
Middle Name:
Last Name:MASSIMO
Suffix:
Gender:F
Credentials:OGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 12TH PL
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:928-778-4300
Mailing Address - Fax:928-771-0920
Practice Address - Street 1:919 12TH PL
Practice Address - Street 2:#1
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:928-778-4300
Practice Address - Fax:928-771-0920
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN034359363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ557291Medicaid