Provider Demographics
NPI:1053883371
Name:VIDALES, ELIZABETH (DNP, FNP-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VIDALES
Suffix:
Gender:
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:
Practice Address - Street 1:306 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2706
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467628Medicaid