Healthcare Provider Details

I. General information

NPI: 1043612310
Provider Name (Legal Business Name): ELLEN T WENGERT NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N SIOUX POINT RD SUITE 100
DAKOTA DUNES SD
57049-5091
US

IV. Provider business mailing address

705 N SIOUX POINT RD SUITE 100
DAKOTA DUNES SD
57049-5091
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-5500
  • Fax: 605-217-5515
Mailing address:
  • Phone: 605-217-5500
  • Fax: 605-217-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA070238
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000911
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: