Provider Demographics
NPI:1164415725
Name:WECKERLY, LORETTA ANN (NP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:ANN
Last Name:WECKERLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1339
Mailing Address - Country:US
Mailing Address - Phone:602-266-2200
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:2632 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1339
Practice Address - Country:US
Practice Address - Phone:602-266-2200
Practice Address - Fax:602-240-6177
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1389363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP17319Medicare UPIN