Healthcare Provider Details

I. General information

NPI: 1770170045
Provider Name (Legal Business Name): MARY ANN WOLFENSON RN, DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 N CENTRAL AVE UNIT 174
PHOENIX AZ
85012-1072
US

IV. Provider business mailing address

4650 N CENTRAL AVE
PHOENIX AZ
85012-1068
US

V. Phone/Fax

Practice location:
  • Phone: 708-925-2502
  • Fax:
Mailing address:
  • Phone: 708-925-2502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number041197834
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: