Provider Demographics
NPI:1346250164
Name:WENTZ, COLLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WENTZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 CEDAR RAVINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6561
Mailing Address - Country:US
Mailing Address - Phone:530-295-1900
Mailing Address - Fax:
Practice Address - Street 1:3105 CEDAR RAVINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6561
Practice Address - Country:US
Practice Address - Phone:530-295-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA470221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21339ZMedicare ID - Type Unspecified
CAP11162Medicare UPIN