Provider Demographics
NPI:1205365723
Name:WHEELER, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36876 W MATTINO LN
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-4903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36876 W. MATTINO LANE
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138
Practice Address - Country:US
Practice Address - Phone:209-205-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5131385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5131OtherAZ DEPT OF HEALTH SERVICES