Healthcare Provider Details

I. General information

NPI: 1326581547
Provider Name (Legal Business Name): SANDRA NICOLE DINWIDDIE A-GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2016
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20823 N CAVE CREEK RD STE 103
PHOENIX AZ
85024-4469
US

IV. Provider business mailing address

3120 W CAREFREE HWY STE 1
PHOENIX AZ
85086-3202
US

V. Phone/Fax

Practice location:
  • Phone: 623-439-5585
  • Fax: 623-439-7775
Mailing address:
  • Phone: 623-439-5585
  • Fax: 623-439-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberAP10488
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP10488
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP10488
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP10488
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: