Healthcare Provider Details

I. General information

NPI: 1639515026
Provider Name (Legal Business Name): DANIELLE WURTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 N 18TH ST
MARYSVILLE KS
66508-1338
US

IV. Provider business mailing address

708 N 18TH ST
MARYSVILLE KS
66508-1338
US

V. Phone/Fax

Practice location:
  • Phone: 785-562-2311
  • Fax:
Mailing address:
  • Phone: 785-562-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-38913
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: