Provider Demographics
NPI:1700274321
Name:ISSANDA STOWATER, FLORA (NP)
Entity Type:Individual
Prefix:
First Name:FLORA
Middle Name:
Last Name:ISSANDA STOWATER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:FLORA
Other - Middle Name:
Other - Last Name:STOWATER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0687
Mailing Address - Country:US
Mailing Address - Phone:480-840-4777
Mailing Address - Fax:
Practice Address - Street 1:1855 S COUNTRY CLUB DR STE 111-130
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6037
Practice Address - Country:US
Practice Address - Phone:480-840-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11721363LF0000X, 363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1700274321Medicaid
AZ47-1340390OtherIRS