Provider Demographics
NPI:1740319219
Name:GUTIERREZ, MARYCONNIE F
Entity type:Individual
Prefix:MRS
First Name:MARYCONNIE
Middle Name:F
Last Name:GUTIERREZ
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 1:7301 N 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-1893
Mailing Address - Country:US
Mailing Address - Phone:623-842-8148
Mailing Address - Fax:623-435-9404
Practice Address - Street 1:7301 N 58TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1893
Practice Address - Country:US
Practice Address - Phone:623-842-8148
Practice Address - Fax:623-435-9404
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPN034068164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse