Provider Demographics
NPI:1326697400
Name:HENKENIUS, WYATT (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:HENKENIUS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 JASPER DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-3312
Mailing Address - Country:US
Mailing Address - Phone:641-745-9378
Mailing Address - Fax:
Practice Address - Street 1:285 FOREST GROVE DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3782
Practice Address - Country:US
Practice Address - Phone:641-745-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0834382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer