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General NPI Number Information
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NPI Number | 1366145591
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Entity Type | Individual
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Provider Name | NATALISSE WAHLSTROM-DAVILA MD
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Gender | Female
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Dates
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Enumeration Date | 03/27/2023
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 1500 S WATSON RD STE C104
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City | BUCKEYE
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State | AZ
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Zip | 85326-8689
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Country | US
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Telephone | 623-025-1755
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 S WATSON RD STE C104
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City | BUCKEYE
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State | AZ
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Zip | 85326-8689
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 23143
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 74447
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License Number State | AZ
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