Basic Information
| Provider Information | |||||||||
| NPI: | 1023461746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUIDO | ||||||||
| FirstName: | JOLE-LANEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AGACNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURKETT | ||||||||
| OtherFirstName: | JOLE-LANEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2680 S VAL VISTA DR | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805075678 | ||||||||
| FaxNumber: | 4805075677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2680 S VAL VISTA DR | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805075678 | ||||||||
| FaxNumber: | 4805075677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2016 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP8838 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 167649 | 05 | AZ | MEDICAID |