Basic Information
| Provider Information | |||||||||
| NPI: | 1023088341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPEELMAN | ||||||||
| FirstName: | LOIS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 EVERGREEN LN | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285372200 | ||||||||
| FaxNumber: | 9285372204 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 EVERGREEN LN | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285372200 | ||||||||
| FaxNumber: | 9285372204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AP1582 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 902397 | 05 | AZ | MEDICAID |