Healthcare Provider Details

I. General information

NPI: 1245341692
Provider Name (Legal Business Name): WENDY L BERTRAM APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N. RUSSELL LONG BLVD
CANYON TX
79016-0001
US

IV. Provider business mailing address

2620 N. RUSSELL LONG BLVD
CANYON TX
79016-0001
US

V. Phone/Fax

Practice location:
  • Phone: 806-651-3287
  • Fax: 806-651-3289
Mailing address:
  • Phone: 806-651-3287
  • Fax: 806-651-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number241305
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: