Basic Information
| Provider Information | |||||||||
| NPI: | 1144246869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALES | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | MCDUFF | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALES | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | ROBYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | STE 375 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774161 | ||||||||
| FaxNumber: | 6022663481 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | STE 375 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774161 | ||||||||
| FaxNumber: | 6022663481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 45501 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 541757 | 05 | AZ | MEDICAID |