Basic Information
Provider Information | |||||||||
NPI: | 1285122408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TELLEZ | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: | WENDY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMH-NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4531 N 16TH ST STE 114 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850165344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022740078 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 16620 N 40TH ST STE E-1 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850323348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024649576 | ||||||||
FaxNumber: | 6026268901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2018 | ||||||||
LastUpdateDate: | 03/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP11453 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0808X | RN179578 | AZ | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 421574 | 05 | AZ |   | MEDICAID |