Provider Demographics
NPI:1851870919
Name:SORENSON, MARY JANE WILD (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:WILD
Last Name:SORENSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 N SPRINGER MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6617
Mailing Address - Country:US
Mailing Address - Phone:520-730-3074
Mailing Address - Fax:
Practice Address - Street 1:5300 S SUTTER DR STE A
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8054
Practice Address - Country:US
Practice Address - Phone:928-251-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily