Provider Demographics
NPI:1790536654
Name:ADVANCED PRACTICE NURSE SOURCE, LLC
Entity Type:Organization
Organization Name:ADVANCED PRACTICE NURSE SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN MILLER
Authorized Official - Last Name:SARHAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-550-6059
Mailing Address - Street 1:5830 W THUNDERBIRD RD STE B8118
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12772 N 58TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1878
Practice Address - Country:US
Practice Address - Phone:801-550-6059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty