Provider Demographics
NPI:1487182648
Name:GOLDEN, MARY RENEE (DNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RENEE
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 E BEVERLY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 N STOCKTON HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4622
Practice Address - Country:US
Practice Address - Phone:928-681-8706
Practice Address - Fax:928-681-8707
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10182363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ276876Medicaid