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General NPI Number Information
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NPI Number | 1982059952
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Entity Type | Organization
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Legal Business Name | PETALOSO INC
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 1867 AIRPORT WAY STE 110B
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City | FAIRBANKS
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State | AK
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Zip | 99701-4054
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Country | US
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Telephone | 907-978-7721
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Fax | 907-452-6330
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Provider Business Mailing Address
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Address Line | 1867 AIRPORT WAY STE 110B
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City | FAIRBANKS
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State | AK
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Zip | 99701-4054
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Country | US
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Telephone | 907-978-7721
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Fax | 907-452-6330
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Authorized Official
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Title or Position | PRESIDENT
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Name | JANICE L STABLES
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Credential | MSN, ANP
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Telephone | 907-978-7721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 420
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License Number State | AK
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