Basic Information
Provider Information | |||||||||
NPI: | 1801210208 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEGENKE | ||||||||
FirstName: | JOANN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3003 N CENTRAL AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850122902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029971098 | ||||||||
FaxNumber: | 6029970484 | ||||||||
Practice Location | |||||||||
Address1: | 903 E STATE HIGHWAY 260 | ||||||||
Address2: |   | ||||||||
City: | PAYSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 855414966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286497997 | ||||||||
FaxNumber: | 9286497996 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2014 | ||||||||
LastUpdateDate: | 02/06/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 329816 | AZ | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 860959487 | 01 | AZ | TAX-ID | OTHER |