Provider Demographics
NPI:1598722324
Name:NALLEY, MITZI D (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MITZI
Middle Name:D
Last Name:NALLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 E PENNY LN
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-4152
Mailing Address - Country:US
Mailing Address - Phone:480-677-3842
Mailing Address - Fax:
Practice Address - Street 1:668 E PENNY LN
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-4152
Practice Address - Country:US
Practice Address - Phone:480-677-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ908238Medicaid
AZ103607Medicare ID - Type Unspecified
AZ908238Medicaid