Provider Demographics
NPI:1003536475
Name:WINGSTROM, TAYLOR (DPT)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:
Last Name:WINGSTROM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 12TH ST APT 3057
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-7728
Mailing Address - Country:US
Mailing Address - Phone:970-768-5521
Mailing Address - Fax:
Practice Address - Street 1:41818 N VENTURE DR STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-3189
Practice Address - Country:US
Practice Address - Phone:623-742-7338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist