Provider Demographics
NPI:1366498529
Name:FREESE, WANDA D (ARNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:D
Last Name:FREESE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1601
Mailing Address - Country:US
Mailing Address - Phone:712-364-2514
Mailing Address - Fax:712-364-4430
Practice Address - Street 1:700 E 2ND ST
Practice Address - Street 2:
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1601
Practice Address - Country:US
Practice Address - Phone:712-364-2514
Practice Address - Fax:712-364-4430
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-050945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q18052Medicare UPIN
IAI12743Medicare PIN