Healthcare Provider Details

I. General information

NPI: 1760258974
Provider Name (Legal Business Name): WENDY G MARBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15151 W CENTERRA DR S
GOODYEAR AZ
85338-2956
US

IV. Provider business mailing address

15151 W CENTERRA DR S
GOODYEAR AZ
85338-2956
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-4810
  • Fax: 623-772-4820
Mailing address:
  • Phone: 623-772-4810
  • Fax: 623-772-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number97560
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: