Healthcare Provider Details

I. General information

NPI: 1356908917
Provider Name (Legal Business Name): WENDY A WINGATE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax: 337-762-3838
Mailing address:
  • Phone: 337-721-7236
  • Fax: 337-721-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204961
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: