Provider Demographics
NPI:1093050767
Name:GASTELUM, CHEYANNE WILDERNESS (LM)
Entity Type:Individual
Prefix:
First Name:CHEYANNE
Middle Name:WILDERNESS
Last Name:GASTELUM
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 E DELGADO ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-5836
Mailing Address - Country:US
Mailing Address - Phone:602-620-0025
Mailing Address - Fax:
Practice Address - Street 1:2236 E. DELGADO ST.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:602-620-0025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ168176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife