Healthcare Provider Details

I. General information

NPI: 1093404535
Provider Name (Legal Business Name): RAE GENE HOVENGA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 9TH ST SW
WAVERLY IA
50677-2929
US

IV. Provider business mailing address

121 E VINE ST
CLARKSVILLE IA
50619-7906
US

V. Phone/Fax

Practice location:
  • Phone: 319-352-4120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA174111
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: