Healthcare Provider Details

I. General information

NPI: 1538276035
Provider Name (Legal Business Name): WLATKA PERIC-KNOWLTON NP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WLATKA PERIC NP, MSN

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARL T. HAYDEN VA MEDICAL CENTER 650 E. INDIAN SCHOOL ROAD (CS111E-2)
PHOENIX AZ
85012-1892
US

IV. Provider business mailing address

4458 E JUANITA AVE
HIGLEY AZ
85236-3461
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax: 602-200-6004
Mailing address:
  • Phone: 602-277-5551
  • Fax: 480-324-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN037759
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: