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General NPI Number Information
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NPI Number | 1588866453
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Entity Type | Organization
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Legal Business Name | APACHE JUNCTION PEDIATRICS
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1075 S IDAHO RD SUITE 206
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City | APACHE JUNCTION
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State | AZ
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Zip | 85219-6496
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Country | US
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Telephone | 480-889-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 1075 S IDAHO RD SUITE 206
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City | APACHE JUNCTION
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State | AZ
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Zip | 85219-6496
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Country | US
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Telephone | 480-889-1234
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Fax |
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Authorized Official
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Title or Position | CERTIFIED PEDIATRIC NURSE PRACTIONE
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Name | MRS. JANET GRADLE
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Credential | CPNP
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Telephone | 480-889-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 34596
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 27900
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 34587
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | AP0241
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License Number State | AZ
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