Healthcare Provider Details

I. General information

NPI: 1487336293
Provider Name (Legal Business Name): DEVYN ALEXANDRIA WENGRAF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W THOMAS RD STE 400
PHOENIX AZ
85013-4238
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3874
  • Fax: 602-406-2335
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN197419
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number299049
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: