Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 37116 | AZ |
NPI | 1003009705 |
---|---|
Provider Name | Dr. Serena Dawn Woods-Grimm |
First Address | Phoenix, AZ 85043-7293 |
Second Address | Phoenix, AZ 85004-8001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2007 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
325855 | (05) | AZ |