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General NPI Number Information
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NPI Number | 1467629469
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Entity Type | Organization
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Legal Business Name | CCENT & FPS
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Dates
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Enumeration Date | 05/09/2008
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 300 W WHITE MOUNTAIN BLVD SUITE D
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City | LAKESIDE
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State | AR
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Zip | 85929-6533
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Country | US
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Telephone | 928-774-1873
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Fax |
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Provider Business Mailing Address
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Address Line | 1340 N RIM DRIVE
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-1311
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Country | US
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Telephone | 928-774-1873
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Fax | 928-774-5525
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. TAMARAH A FRATIANNI
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Credential | D.O
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Telephone | 928-774-1873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number | 3000
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 3000
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License Number State | AZ
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