Provider Demographics
NPI:1447605274
Name:LEGACY PRIMARY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LEGACY PRIMARY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MS./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMEEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:520-975-4883
Mailing Address - Street 1:7959 N THORNYDALE RD
Mailing Address - Street 2:#91933
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-1443
Mailing Address - Country:US
Mailing Address - Phone:520-975-4883
Mailing Address - Fax:
Practice Address - Street 1:7959 N THORNYDALE RD
Practice Address - Street 2:#91933
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-1443
Practice Address - Country:US
Practice Address - Phone:520-975-4883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ803226Medicaid