Arizona Vaccines For Children (VFC) Program - DOC

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                 2012 Arizona Vaccines for Children (VFC) Provider License Information

Please list all Physicians, Physician’s Assistants, and Nurse Practitioners in the practice who will be prescribing
immunizations to Arizona VFC-eligible children, the provider’s Medicaid/AHCCCS number (if applicable),
and medical license number. Please attach a separate page if more space is needed.

        Name as appears on License                    Title                 Provider               Medical
          (Last, First, MI)                        (MD, DO,                AHCCCS/                 License
                                                 PA, FNP, PNP)           Medicaid Number           Number

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Please contact the Vaccine Center at (602) 364-3642 whenever there is a change to your profile information.
Notify us of any change in the name of your practice, address, phone number, contact name, number of
providers, or number of children served. This information must be up-to-date to ensure prompt and proper
vaccine ordering.