Healthcare Provider Details

I. General information

NPI: 1245012293
Provider Name (Legal Business Name): ANGELA MARIE WENGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 SILVER LAKE HWY
BROOKLYN MI
49230-8459
US

IV. Provider business mailing address

11600 SILVER LAKE HWY
BROOKLYN MI
49230-8628
US

V. Phone/Fax

Practice location:
  • Phone: 517-438-6222
  • Fax:
Mailing address:
  • Phone: 517-438-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP.AP.70115228-NP
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704270543
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4704270543NSA230TW
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4704270543NSA230TW
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: