Basic Information
| Provider Information | |||||||||
| NPI: | 1538346994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACKLEY | ||||||||
| FirstName: | EMMERLL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3505 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287571199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1741 SYCAMORE AVE | ||||||||
| Address2: | 3508 WESTERN AVE | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287571199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 06/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R184121 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP3654 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 519975 | 05 | AZ | MEDICAID |