Provider Demographics
NPI:1912141573
Name:AFFELDT, THOMAS O (LPN)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:O
Last Name:AFFELDT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2903
Mailing Address - Country:US
Mailing Address - Phone:602-664-7927
Mailing Address - Fax:602-664-7998
Practice Address - Street 1:5601 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2903
Practice Address - Country:US
Practice Address - Phone:602-664-7927
Practice Address - Fax:602-664-7998
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP041491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse