Healthcare Provider Details

I. General information

NPI: 1376029942
Provider Name (Legal Business Name): ALESHA MICHELE BLACKETER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N WINDING BROOK RD
FLAGSTAFF AZ
86001-0972
US

IV. Provider business mailing address

PO BOX 29675 DEPT 2025
PHOENIX AZ
85038
US

V. Phone/Fax

Practice location:
  • Phone: 928-556-0060
  • Fax:
Mailing address:
  • Phone: 928-814-3332
  • Fax: 480-987-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10186
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: