Healthcare Provider Details

I. General information

NPI: 1720699788
Provider Name (Legal Business Name): SANDRA DINWIDDIE NP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SANDRA NICOLE DINWIDDIE
Title or Position: OWNER
Credential:
Phone: 623-439-5585