Provider Demographics
NPI:1891215455
Name:FARRIS, RAUCHEL CHELAN
Entity Type:Individual
Prefix:
First Name:RAUCHEL
Middle Name:CHELAN
Last Name:FARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-263-4722
Mailing Address - Fax:928-263-4794
Practice Address - Street 1:2202 N STOCKTON HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4622
Practice Address - Country:US
Practice Address - Phone:928-681-8706
Practice Address - Fax:928-681-8707
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ283453Medicaid