Healthcare Provider Details

I. General information

NPI: 1427985084
Provider Name (Legal Business Name): GWYNETH ROCELLE TAWAGON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3839 W CAMELBACK RD
PHOENIX AZ
85019-2512
US

IV. Provider business mailing address

3839 W CAMELBACK RD
PHOENIX AZ
85019-2512
US

V. Phone/Fax

Practice location:
  • Phone: 602-764-6064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number285867
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: