Provider Demographics
NPI:1578675047
Name:FARDELOS, THERESA E (CNM)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:FARDELOS
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:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 730
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-4628
Practice Address - Fax:602-798-9854
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ091351367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ459124Medicaid
AZZ113733Medicare PIN