Provider Demographics
NPI:1134130396
Name:KENNER, WENDY L (PA)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:L
Last Name:KENNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1802
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-1802
Mailing Address - Country:US
Mailing Address - Phone:720-255-2953
Mailing Address - Fax:
Practice Address - Street 1:2551 W 84TH AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3807
Practice Address - Country:US
Practice Address - Phone:720-255-2953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2199363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42121540Medicaid
CO527213OtherUPIN
CO527213OtherUPIN
COC483178Medicare PIN