=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285698720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANET MARIE NETTLETON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 02/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5151 E HWY 90
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-803-6644
-----------------------------------------------------
Fax | 520-459-3193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5151 E HIGHWAY 90
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-803-6644
-----------------------------------------------------
Fax | 520-459-3193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0203X
-----------------------------------------------------
Taxonomy Name | Therapeutic Radiology Physician
-----------------------------------------------------
License Number | 27594
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------