Healthcare Provider Details

I. General information

NPI: 1790281129
Provider Name (Legal Business Name): WENDY MARIE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6124 E BROWN RD STE 102
MESA AZ
85205-4959
US

IV. Provider business mailing address

6124 E BROWN RD STE 102
MESA AZ
85205-4959
US

V. Phone/Fax

Practice location:
  • Phone: 480-229-4094
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86063644
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: