Healthcare Provider Details

I. General information

NPI: 1295868180
Provider Name (Legal Business Name): CAROL JEAN WOSTAL REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 HUALAPAI WAY
PEACH SPRINGS AZ
86434
US

IV. Provider business mailing address

2380 N ALPHA ST
KINGMAN AZ
86401-5000
US

V. Phone/Fax

Practice location:
  • Phone: 928-769-2900
  • Fax: 928-769-2971
Mailing address:
  • Phone: 928-753-4394
  • Fax: 928-769-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN017386
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: