Provider Demographics
NPI:1386097335
Name:WENNERSTEN, AMANDA ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:WENNERSTEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4452
Mailing Address - Country:US
Mailing Address - Phone:480-325-5869
Mailing Address - Fax:
Practice Address - Street 1:4831 N 11TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-3681
Practice Address - Country:US
Practice Address - Phone:602-424-2101
Practice Address - Fax:602-424-2103
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN164357163W00000X
AZAP8586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse