Provider Demographics
NPI:1659574515
Name:AVILA, MARISOL TATIANA (ARNP-C)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:TATIANA
Last Name:AVILA
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5707
Mailing Address - Country:US
Mailing Address - Phone:602-322-1315
Mailing Address - Fax:602-889-7392
Practice Address - Street 1:1311 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5707
Practice Address - Country:US
Practice Address - Phone:602-322-1315
Practice Address - Fax:602-889-7392
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN135266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN135266OtherAZ STATE LICENSE #