MEDICARE: WILLOW OAK, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN083151	AZ

General Provider Information

NPI Number	:	1265500656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW OAK, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1549
Second Line	:
City	:	COLORADO CITY
State	:	AZ
Zip	:	86021-1549
Country	:	US
Telephone Number	:	928-875-8750
Fax Number	:	928-875-8752

Provider Business Practice Location Address
First Line	:	1675 S. BERRY KNOLL BLVD
Second Line	:
City	:	COLORADO CITY
State	:	AZ
Zip	:	86021-1549
Country	:	US
Telephone Number	:	928-875-8750
Fax Number	:	928-875-8752

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MS. JOANNE TIMPSON YARRISH
Credential	:	FNP, CNM
Telephone Number	:	928-875-8750

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	06/13/2008

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