Provider Demographics
NPI:1093060501
Name:WENTZEL, DANA M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:M
Last Name:WENTZEL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2436
Mailing Address - Fax:
Practice Address - Street 1:4241 HIGHWAY 14 WEST
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822
Practice Address - Country:US
Practice Address - Phone:618-724-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043085910164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse