Provider Demographics
NPI:1447768130
Name:DE RETANA, NATALIJA (AGNP)
Entity Type:Individual
Prefix:
First Name:NATALIJA
Middle Name:
Last Name:DE RETANA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5882 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5882 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9455
Practice Address - Country:US
Practice Address - Phone:928-793-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10895363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology