Provider Demographics
NPI:1134523624
Name:RENTFROW, KIRSTEN DOMINIQUE HART (NP)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:DOMINIQUE HART
Last Name:RENTFROW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:DOMINIQUE
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 S CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-0504
Mailing Address - Country:US
Mailing Address - Phone:520-407-5600
Mailing Address - Fax:
Practice Address - Street 1:18857 S LA CANADA DR
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-7990
Practice Address - Country:US
Practice Address - Phone:520-407-5800
Practice Address - Fax:520-407-5990
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7353363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ985949Medicaid
AZ985949Medicaid