Provider Demographics
NPI:1194989129
Name:WADLEIGH, IVONNE LOREN A
Entity type:Individual
Prefix:
First Name:IVONNE
Middle Name:LOREN A
Last Name:WADLEIGH
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 1:100 E CORTE RANCHO COLINA
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-9061
Mailing Address - Country:US
Mailing Address - Phone:520-207-1687
Mailing Address - Fax:
Practice Address - Street 1:100 E CORTE RANCHO COLINA
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-9061
Practice Address - Country:US
Practice Address - Phone:520-207-1687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ874986171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ874986OtherSTATE OF AZ PFH LICENSE