Healthcare Provider Details

I. General information

NPI: 1871029090
Provider Name (Legal Business Name): MRS. CAROLYN WANYAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44880 W PORTABELLO ROAD
MARICOPA AZ
85139
US

IV. Provider business mailing address

44880 W PORTABELLO ROAD
MARICOPA AZ
85139
US

V. Phone/Fax

Practice location:
  • Phone: 520-494-2626
  • Fax:
Mailing address:
  • Phone: 480-374-0486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberAL10166H
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: