Healthcare Provider Details

I. General information

NPI: 1609268085
Provider Name (Legal Business Name): WANDA CHRISTINE MINENNA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 MAIN ST
BENNINGTON VT
05201-2845
US

IV. Provider business mailing address

600 BLAIR PARK RD STE 285
WILLISTON VT
05495-7855
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-2343
  • Fax: 802-442-4636
Mailing address:
  • Phone: 802-288-1140
  • Fax: 802-288-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0134955
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: