Provider Demographics
NPI:1700470275
Name:FORMENTIN, REGINA MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:FORMENTIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 E COCHISE DR UNIT 2104
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-4931
Mailing Address - Country:US
Mailing Address - Phone:734-309-9908
Mailing Address - Fax:
Practice Address - Street 1:11500 E COCHISE DR UNIT 2104
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-4931
Practice Address - Country:US
Practice Address - Phone:734-309-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ254655363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health