Provider Demographics
NPI:1770958639
Name:O'BRIEN, SHERRY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25816
Mailing Address - Street 2:
Mailing Address - City:MUNDS PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:86017-5816
Mailing Address - Country:US
Mailing Address - Phone:480-466-1311
Mailing Address - Fax:
Practice Address - Street 1:2000 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8759
Practice Address - Country:US
Practice Address - Phone:928-226-6400
Practice Address - Fax:928-226-6411
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN170043163W00000X
AZAP10273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ219446OtherMEDICARE
AZ282324Medicaid