Healthcare Provider Details

I. General information

NPI: 1164415725
Provider Name (Legal Business Name): LORETTA ANN WECKERLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 N 20TH ST
PHOENIX AZ
85006-1339
US

IV. Provider business mailing address

2632 N 20TH ST
PHOENIX AZ
85006-1339
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-2200
  • Fax: 602-240-6177
Mailing address:
  • Phone: 602-266-2200
  • Fax: 602-240-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP1389
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: