Healthcare Provider Details

I. General information

NPI: 1134446552
Provider Name (Legal Business Name): LAURA KAILEY WINKLEBLACK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2010
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST FL 2
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

1441 N 12TH ST FL 2
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-6040
  • Fax: 602-839-3411
Mailing address:
  • Phone: 602-839-6040
  • Fax: 602-839-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number011021
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License NumberRN594783
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP4521
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: