Healthcare Provider Details

I. General information

NPI: 1740302728
Provider Name (Legal Business Name): FOUR PEAKS ELEMENTARY SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N IDAHO RD
APACHE JUNCTION AZ
85219-1716
US

IV. Provider business mailing address

4126 N COLT RD
APACHE JUNCTION AZ
85219-9643
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-1110
  • Fax:
Mailing address:
  • Phone: 480-516-9332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateAZ

VIII. Authorized Official

Name: MRS. KIMBERLY PAM DICKERSON
Title or Position: SCHOOL NURSE
Credential: L.P.N.
Phone: 480-982-1110