Provider Demographics
NPI:1558647636
Name:WENCKUS, STACIA LYNN (RN)
Entity Type:Individual
Prefix:MS
First Name:STACIA
Middle Name:LYNN
Last Name:WENCKUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1839
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN170489163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse