Healthcare Provider Details

I. General information

NPI: 1922923119
Provider Name (Legal Business Name): MICHAELA WIXOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N 4TH ST
FLAGSTAFF AZ
86004-1710
US

IV. Provider business mailing address

9894 HERITAGE DR
FLAGSTAFF AZ
86004-8214
US

V. Phone/Fax

Practice location:
  • Phone: 928-864-6473
  • Fax: 928-773-4090
Mailing address:
  • Phone: 928-864-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number281752
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: