MEDICARE: PAINTED MOUNTAIN CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1477254746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAINTED MOUNTAIN CLINIC, PLLC

Provider Business Mailing Address
First Line	:	2245 N NORRIS AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-3825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3038 E FORT LOWELL RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1501
Country	:	US
Telephone Number	:	520-744-3131
Fax Number	:	520-744-3131

Authorized Official
Title or Position	:	OWNER
Name	:	LORETTA KRAMER
Credential	:
Telephone Number	:	520-591-6065

Provider Enumeration Date	:	03/14/2023
Last Update Date	:	03/20/2023

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