Healthcare Provider Details

I. General information

NPI: 1326527508
Provider Name (Legal Business Name): SHIRENE WOODHAM DNP FNP-BC AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 S POWER RD STE 129
MESA AZ
85212-3627
US

IV. Provider business mailing address

4135 S POWER RD STE 129
MESA AZ
85212-3627
US

V. Phone/Fax

Practice location:
  • Phone: 480-751-3091
  • Fax: 480-751-3095
Mailing address:
  • Phone: 480-751-3091
  • Fax: 480-751-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number226355
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226355
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number226355
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number226355
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: