Provider Demographics
NPI:1376160978
Name:STOKUM, LANDIS BROOK (PMHNP)
Entity Type:Individual
Prefix:
First Name:LANDIS
Middle Name:BROOK
Last Name:STOKUM
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 E BACKMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-4290
Mailing Address - Country:US
Mailing Address - Phone:480-274-9033
Mailing Address - Fax:
Practice Address - Street 1:2730 S VAL VISTA DR STE 146
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1679
Practice Address - Country:US
Practice Address - Phone:480-542-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP243406363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health