Healthcare Provider Details

I. General information

NPI: 1720071608
Provider Name (Legal Business Name): UNITED STATES AIR FORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD
LUKE AFB AZ
85309-1529
US

IV. Provider business mailing address

2407 N 127TH LN
AVONDALE AZ
85323-6576
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-9725
  • Fax: 623-856-7567
Mailing address:
  • Phone: 623-536-4774
  • Fax: 623-856-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberRN114749
License Number StateAZ

VIII. Authorized Official

Name: MRS. PATTI JO PETERSON-BALLIET
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: CPNP
Phone: 626-536-4774