Basic Information
| Provider Information | |||||||||
| NPI: | 1508035551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEWECK | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
| FaxNumber: | 6022663481 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 S VAL VISTA DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029336345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2008 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0002X | RN098549 | AZ | N | Nursing Service Providers | Registered Nurse | Neonatal Intensive Care | 363LN0000X | 098549 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | TBD | 01 | AZ | AHCCCS | OTHER | TBD | 05 | AZ | MEDICAID |