Provider Demographics
NPI:1043612310
Name:WENGERT, ELLEN T (NP-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:T
Last Name:WENGERT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N SIOUX POINT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5091
Mailing Address - Country:US
Mailing Address - Phone:605-217-5500
Mailing Address - Fax:605-217-5515
Practice Address - Street 1:705 N SIOUX POINT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5091
Practice Address - Country:US
Practice Address - Phone:605-217-5500
Practice Address - Fax:605-217-5515
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA070238363LF0000X
SDCP000911363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily