Provider Demographics
NPI:1962154740
Name:WIGGINS, JONI
Entity type:Individual
Prefix:
First Name:JONI
Middle Name:
Last Name:WIGGINS
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 1:29116 N 250TH AVE
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-1039
Mailing Address - Country:US
Mailing Address - Phone:602-620-6431
Mailing Address - Fax:
Practice Address - Street 1:2035 MESQUITE AVE STE D
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-505-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP051949164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse