Provider Demographics
NPI:1992715379
Name:VAN WIE, KAREN LYNNE (RN MS, PSY-MH NP)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LYNNE
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:RN MS, PSY-MH NP
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:LYNNE
Other - Last Name:CRUIKSHANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN MS
Mailing Address - Street 1:4705 W MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757-9395
Mailing Address - Country:US
Mailing Address - Phone:520-461-9880
Mailing Address - Fax:520-578-6416
Practice Address - Street 1:2925 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2801
Practice Address - Country:US
Practice Address - Phone:520-461-9880
Practice Address - Fax:520-578-6416
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN037770163WP0808X
AZAP2195363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ948408Medicaid
AZ948408Medicaid