MEDICARE: AMANDA ELIZABETH WENNERSTEN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN164357	AZ
2	363LF0000X	Family Nurse Practitioner	AP8586	AZ

General Provider Information

NPI Number	:	1386097335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ELIZABETH WENNERSTEN FNP

Provider Business Mailing Address
First Line	:	6015 E BROWN RD
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-4452
Country	:	US
Telephone Number	:	480-325-5869
Fax Number	:

Provider Business Practice Location Address
First Line	:	4831 N 11TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3681
Country	:	US
Telephone Number	:	602-424-2101
Fax Number	:	602-424-2103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2016
Last Update Date	:	04/19/2022

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