Provider Demographics
NPI:1013784008
Name:WELLWOOD, MARIBEL GRIMALDO
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:GRIMALDO
Last Name:WELLWOOD
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 1:1612 N 202ND AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-9736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1612 N 202ND AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-9736
Practice Address - Country:US
Practice Address - Phone:520-907-1683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program