Provider Demographics
NPI:1306212972
Name:FETTER, WENDY SUE
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:FETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:SUE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6425 NEW CARLISLE PIKE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-3236
Mailing Address - Country:US
Mailing Address - Phone:419-234-4833
Mailing Address - Fax:
Practice Address - Street 1:25 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-2278
Practice Address - Country:US
Practice Address - Phone:937-325-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05400224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant