Provider Demographics
NPI:1477315323
Name:PROVERA, JILL (CNM)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PROVERA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 E MCNEIL ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5579
Mailing Address - Country:US
Mailing Address - Phone:480-431-5690
Mailing Address - Fax:
Practice Address - Street 1:2152 S VINEYARD STE 138
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6882
Practice Address - Country:US
Practice Address - Phone:480-539-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ301662176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife