Provider Demographics
NPI:1750051033
Name:PISIAK, AGNIESZKA (PMHNP)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:PISIAK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 W HEREFORD DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5042
Mailing Address - Country:US
Mailing Address - Phone:480-282-7826
Mailing Address - Fax:
Practice Address - Street 1:1030 E GUADALUPE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3044
Practice Address - Country:US
Practice Address - Phone:480-491-1898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ263269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty