=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316481625
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALVIN WIENTJES CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2016
-----------------------------------------------------
Last Update Date | 03/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4568 QUAIL HOLLOW DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-5396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-638-3656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4568 QUAIL HOLLOW DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-5396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-638-3656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 416443
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041.446613
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 199315
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 209.015519
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 3010948
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------