Provider Demographics
NPI:1922078922
Name:HALL, WENDY LEE (CNM)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LEE
Last Name:HALL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:LEE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0617
Mailing Address - Country:US
Mailing Address - Phone:928-535-4539
Mailing Address - Fax:928-535-4895
Practice Address - Street 1:261 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5316
Practice Address - Country:US
Practice Address - Phone:928-536-5377
Practice Address - Fax:928-535-7656
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0244367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ490467Medicaid
79848Medicare ID - Type Unspecified
S93017Medicare UPIN