Provider Demographics
NPI:1881391803
Name:FAMILY HEALTH MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:FAMILY HEALTH MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/PMHNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NJANTE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C,PMHNP-BC
Authorized Official - Phone:510-355-5652
Mailing Address - Street 1:10445 E PIVITOL AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8037
Mailing Address - Country:US
Mailing Address - Phone:510-355-5652
Mailing Address - Fax:
Practice Address - Street 1:10445 E PIVITOL AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-8037
Practice Address - Country:US
Practice Address - Phone:510-355-5652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty