Provider Demographics
NPI:1619476389
Name:FUDER-BOEHM, ANNA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:FUDER-BOEHM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 S DOBSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 E MITCHELL DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2330
Practice Address - Country:US
Practice Address - Phone:602-264-4331
Practice Address - Fax:602-264-4095
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112408363L00000X
NE2041363LP0808X
AZ277703363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner