Provider Demographics
NPI:1457008617
Name:WAGENVELT, BETH A (NP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:WAGENVELT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:WIERENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAIDEN NAME
Mailing Address - Street 1:1815 HENSON AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1510
Mailing Address - Country:US
Mailing Address - Phone:269-492-6500
Mailing Address - Fax:269-492-6461
Practice Address - Street 1:1815 HENSON AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1510
Practice Address - Country:US
Practice Address - Phone:269-492-6500
Practice Address - Fax:269-492-6461
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704264004363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner