Healthcare Provider Details

I. General information

NPI: 1053772830
Provider Name (Legal Business Name): DEANNA WENNBERG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E. MICHIGAN AVENUE
LANSING MI
48912
US

IV. Provider business mailing address

1200 E MICHIGAN AVE STE 101
LANSING MI
48912-1800
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 517-364-5552
  • Fax: 517-364-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704242410
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: