Provider Demographics
NPI:1457708638
Name:BOOTH, MONICA MONTANO (NP)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:MONTANO
Last Name:BOOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 W AUTO DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1016
Mailing Address - Country:US
Mailing Address - Phone:602-362-2983
Mailing Address - Fax:480-565-4552
Practice Address - Street 1:1437 W AUTO DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1016
Practice Address - Country:US
Practice Address - Phone:602-362-2983
Practice Address - Fax:480-565-4552
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8874363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ226022Medicaid