Healthcare Provider Details

I. General information

NPI: 1497599690
Provider Name (Legal Business Name): MICHAEL JOHN WENGER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11702 YELM HWY SE
OLYMPIA WA
98513-9109
US

IV. Provider business mailing address

102 S MARION AVE
BREMERTON WA
98312-3639
US

V. Phone/Fax

Practice location:
  • Phone: 541-817-6194
  • Fax:
Mailing address:
  • Phone: 541-817-6194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN61104015
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN61104015
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: