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General NPI Number Information
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NPI Number | 1720071608
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Entity Type | Organization
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Legal Business Name | UNITED STATES AIR FORCE
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Dates
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Enumeration Date | 08/25/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7219 N LITCHFIELD RD
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City | LUKE AFB
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State | AZ
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Zip | 85309-1529
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Country | US
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Telephone | 623-856-9725
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Fax | 623-856-7567
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Provider Business Mailing Address
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Address Line | 2407 N 127TH LN
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City | AVONDALE
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State | AZ
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Zip | 85323-6576
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Country | US
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Telephone | 623-536-4774
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Fax | 623-856-7567
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Authorized Official
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Title or Position | PEDIATRIC NURSE PRACTITIONER
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Name | MRS. PATTI JO PETERSON-BALLIET
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Credential | CPNP
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Telephone | 626-536-4774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 286500000X
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Taxonomy Name | Military Hospital
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License Number | RN114749
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License Number State | AZ
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