Healthcare Provider Details

I. General information

NPI: 1962429795
Provider Name (Legal Business Name): KIM RENAE WENTZ M.D.,M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

IV. Provider business mailing address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

V. Phone/Fax

Practice location:
  • Phone: 503-981-5348
  • Fax: 503-981-0423
Mailing address:
  • Phone: 503-981-5348
  • Fax: 503-981-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD28910
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: