Healthcare Provider Details

I. General information

NPI: 1912258716
Provider Name (Legal Business Name): PAMELA R. WENTWORTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 S. MAIN ST.
DAYTON IA
45402
US

IV. Provider business mailing address

349 S. MAIN ST.
DAYTON IA
45402-2715
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-3450
  • Fax: 937-461-9584
Mailing address:
  • Phone: 937-461-3450
  • Fax: 937-461-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number278653
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: