Provider Demographics
NPI:1902304678
Name:PEMBROKE, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:PEMBROKE
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 1:4531 N 16TH ST STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5344
Mailing Address - Country:US
Mailing Address - Phone:602-464-9576
Mailing Address - Fax:
Practice Address - Street 1:16620 N 40TH ST STE E-1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3348
Practice Address - Country:US
Practice Address - Phone:602-464-9576
Practice Address - Fax:602-626-8901
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY650554163WA0400X
AZ271416363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)