Healthcare Provider Details

I. General information

NPI: 1801493184
Provider Name (Legal Business Name): STEPHANIE LEIGH WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 N 7TH ST STE 105
PHOENIX AZ
85014-1803
US

IV. Provider business mailing address

6040 N 7TH ST STE 105
PHOENIX AZ
85014-1803
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-7430
  • Fax: 602-279-5333
Mailing address:
  • Phone: 602-277-7430
  • Fax: 602-279-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN189915
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number253670
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: