Healthcare Provider Details

I. General information

NPI: 1306948245
Provider Name (Legal Business Name): WENDY AMANDA GRAVELLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY AMANDA MEYER RN

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 JEFFERSON ST NORTH
WADENA MN
56482
US

IV. Provider business mailing address

13436 COUNTY ROAD 101
WADENA MN
56482
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-3510
  • Fax: 218-631-7496
Mailing address:
  • Phone: 218-632-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR1540705
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: