Healthcare Provider Details

I. General information

NPI: 1255300885
Provider Name (Legal Business Name): NICOLE LEA WENTWORTH HARTUNG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE L WENTWORTH M.D.

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number43587
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: