Provider Demographics
NPI:1720071608
Name:UNITED STATES AIR FORCE
Entity Type:Organization
Organization Name:UNITED STATES AIR FORCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:PETERSON-BALLIET
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:626-536-4774
Mailing Address - Street 1:2407 N 127TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-6576
Mailing Address - Country:US
Mailing Address - Phone:623-536-4774
Mailing Address - Fax:623-856-7567
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-9725
Practice Address - Fax:623-856-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN114749286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN114749OtherNURSING LICENSE