Healthcare Provider Details

I. General information

NPI: 1073871976
Provider Name (Legal Business Name): ANDREA SUE WENNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 NE STALLINGS DR
NACOGDOCHES TX
75965-1608
US

IV. Provider business mailing address

161 CARDOVA DR
MAX MEADOWS VA
24360-3651
US

V. Phone/Fax

Practice location:
  • Phone: 936-560-5668
  • Fax:
Mailing address:
  • Phone: 936-371-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10043663
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: