Provider Demographics
NPI:1114416989
Name:WARDLE-SANFORD, NICHOLE BRIANNA
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:BRIANNA
Last Name:WARDLE-SANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:BRIANNA
Other - Last Name:WARDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5868 E KATHLEEN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5868 E KATHLEEN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1861
Practice Address - Country:US
Practice Address - Phone:623-256-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN154823163WG0000X
AZAP222546208M00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist