Provider Demographics
NPI:1205897543
Name:PUTNAM, JANICE L (FNP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:L
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S CLEARVIEW AVE STE 100
Mailing Address - Street 2:URGENT CARE EXTRA
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:641 W WARNER RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-7266
Practice Address - Country:US
Practice Address - Phone:480-722-9828
Practice Address - Fax:480-722-9831
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN047681363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578403Medicaid
P75136Medicare UPIN
AZ578403Medicaid
107684Medicare ID - Type Unspecified