Healthcare Provider Details

I. General information

NPI: 1437013562
Provider Name (Legal Business Name): VERDE VALLEY FUNCTIONAL WELLNESS CENTER & MEDICINAL APOTHECARY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S MAIN ST STE 1A
COTTONWOOD AZ
86326-4621
US

IV. Provider business mailing address

830 S MAIN ST STE 1A
COTTONWOOD AZ
86326-4621
US

V. Phone/Fax

Practice location:
  • Phone: 928-852-0472
  • Fax:
Mailing address:
  • Phone: 928-852-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY MAE CANDELARIA
Title or Position: OWNER/PROVIDER
Credential: NP
Phone: 928-607-1971