Healthcare Provider Details

I. General information

NPI: 1205175304
Provider Name (Legal Business Name): MARLENE ELIZABETH WILSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11022 S 51ST ST STE 250
PHOENIX AZ
85044-4308
US

IV. Provider business mailing address

11022 S 51ST ST STE 250
PHOENIX AZ
85044-4308
US

V. Phone/Fax

Practice location:
  • Phone: 480-939-6137
  • Fax: 602-429-8445
Mailing address:
  • Phone: 480-939-6137
  • Fax: 602-429-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN174104
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number236775
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: