Provider Demographics
NPI:1164612669
Name:DORWORTH, WENDY D (CFNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:D
Last Name:DORWORTH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 S MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4030
Mailing Address - Country:US
Mailing Address - Phone:217-789-1403
Mailing Address - Fax:217-789-1825
Practice Address - Street 1:1836 S MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4030
Practice Address - Country:US
Practice Address - Phone:217-789-1403
Practice Address - Fax:217-789-1825
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid