Healthcare Provider Details

I. General information

NPI: 1982784559
Provider Name (Legal Business Name): MINDY E WENGER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WESTSIDE DR NW STE 103
CLEVELAND TN
37312-3699
US

IV. Provider business mailing address

2700 WESTSIDE DR NW STE 103
CLEVELAND TN
37312-3699
US

V. Phone/Fax

Practice location:
  • Phone: 423-472-1511
  • Fax: 423-479-9202
Mailing address:
  • Phone: 423-472-1511
  • Fax: 423-479-9202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN274947
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP06985
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: