Provider Demographics
NPI:1730382045
Name:MOMON, DEBRA (LPN)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:
Last Name:MOMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7349 W GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-5740
Mailing Address - Country:US
Mailing Address - Phone:623-691-5015
Mailing Address - Fax:
Practice Address - Street 1:3637 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-2503
Practice Address - Country:US
Practice Address - Phone:623-691-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP024121164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse