=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073549960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE N WILSON CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4212 N 16TH ST OB/GYN DEPARTMENT
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-263-1200
-----------------------------------------------------
Fax | 602-263-1692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 N MILLER RD UNIT 34
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85257-3659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-656-3390
-----------------------------------------------------
Fax | 602-263-1692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN079372
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 153
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------