Basic Information
| Provider Information | |||||||||
| NPI: | 1992751499 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6026856001 | ||||||||
| Practice Location | |||||||||
| Address1: | 628 N CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852015064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6026856001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN080120 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 425828 | 05 | AZ | MEDICAID |