Healthcare Provider Details

I. General information

NPI: 1871055921
Provider Name (Legal Business Name): WAYNETTE LESLIE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N 5TH ST
PHOENIX AZ
85004-2157
US

IV. Provider business mailing address

PO BOX 4000
POLACCA AZ
86042-4000
US

V. Phone/Fax

Practice location:
  • Phone: 602-827-2450
  • Fax:
Mailing address:
  • Phone: 928-737-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: