Healthcare Provider Details

I. General information

NPI: 1316481625
Provider Name (Legal Business Name): CALVIN WIENTJES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4568 QUAIL HOLLOW DR
PADUCAH KY
42001-5396
US

IV. Provider business mailing address

4568 QUAIL HOLLOW DR
PADUCAH KY
42001-5396
US

V. Phone/Fax

Practice location:
  • Phone: 618-638-3656
  • Fax:
Mailing address:
  • Phone: 618-638-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number416443
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.446613
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number199315
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.015519
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3010948
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: