Provider Demographics
NPI:1093477622
Name:WOESTMAN, MIEKE DEANINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MIEKE
Middle Name:DEANINE
Last Name:WOESTMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 YUCCA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-1337
Mailing Address - Country:US
Mailing Address - Phone:817-808-2571
Mailing Address - Fax:
Practice Address - Street 1:309 REGENCY PKWY STE 107
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5165
Practice Address - Country:US
Practice Address - Phone:817-808-2571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1045320363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner