Provider Demographics
NPI:1083802987
Name:WENTZEL, MARY A (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:WENTZEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2451 INTELLIPLEX DR STE 220
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8581
Practice Address - Country:US
Practice Address - Phone:317-893-1900
Practice Address - Fax:317-398-1849
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2023-09-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71002325A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200938960Medicaid