Provider Demographics
NPI:1275399685
Name:WILSON, SHIANNA
Entity type:Individual
Prefix:
First Name:SHIANNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 4500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2171
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:13555 W MCDOWELL RD STE 101
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2625
Practice Address - Country:US
Practice Address - Phone:623-935-4700
Practice Address - Fax:623-935-4707
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty