Healthcare Provider Details

I. General information

NPI: 1215070743
Provider Name (Legal Business Name): WENDY LEIGH COUCH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 418
APO AE
09058
DE

IV. Provider business mailing address

CMR 442
APO AE
09042
DE

V. Phone/Fax

Practice location:
  • Phone: 4962217795137
  • Fax:
Mailing address:
  • Phone: 496221172941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2050740
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: