Healthcare Provider Details

I. General information

NPI: 1205039070
Provider Name (Legal Business Name): JACQUELINE ALLEN WUNDERLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE ALLEN-WUNDERLY M.D.

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10814 S INTERLAKEN
RICHLAND MI
49083-8514
US

IV. Provider business mailing address

10814 S INTERLAKEN
RICHLAND MI
49083-8514
US

V. Phone/Fax

Practice location:
  • Phone: 269-629-5231
  • Fax:
Mailing address:
  • Phone: 269-629-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301049069
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: