Provider Demographics
NPI:1164608774
Name:FISKE, JANETTE LUANNE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JANETTE
Middle Name:LUANNE
Last Name:FISKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 W CARLOS AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-1846
Mailing Address - Country:US
Mailing Address - Phone:928-524-2123
Mailing Address - Fax:928-524-6367
Practice Address - Street 1:294 W CARLOS AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-1846
Practice Address - Country:US
Practice Address - Phone:928-524-2123
Practice Address - Fax:928-524-6367
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ284312Medicaid