Provider Demographics
NPI:1073030607
Name:WANZENRIED, SEPTEMBER LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:SEPTEMBER
Middle Name:LEIGH
Last Name:WANZENRIED
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 CASS ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-2818
Mailing Address - Country:US
Mailing Address - Phone:402-301-4348
Mailing Address - Fax:
Practice Address - Street 1:6901 S 84TH ST
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2004207Q00000X
IAA148987363LF0000X
NE112351363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine