Provider Demographics
NPI:1447675665
Name:WADSWORTH, MICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30474 N REBECCA LN
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4626
Mailing Address - Country:US
Mailing Address - Phone:480-677-7500
Mailing Address - Fax:480-982-1708
Practice Address - Street 1:1785 N. IDAHO RD.
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119
Practice Address - Country:US
Practice Address - Phone:480-677-7500
Practice Address - Fax:480-982-1708
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ860951340376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860951340OtherTAX ID