Basic Information
| Provider Information | |||||||||
| NPI: | 1912295106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYONLANDS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 618 S. CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
| FaxNumber: | 9284281555 | ||||||||
| Practice Location | |||||||||
| Address1: | 618 S. CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
| FaxNumber: | 9284281555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRAPER | ||||||||
| AuthorizedOfficialFirstName: | JO-ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9284281500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | FNP-C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | AP2847 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.