Provider Demographics
NPI:1518115872
Name:WENTWORTH, MARY LOUISE (MS, ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:MS, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SW PEPPER TREE LN
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66611-2056
Mailing Address - Country:US
Mailing Address - Phone:785-233-0516
Mailing Address - Fax:785-233-3806
Practice Address - Street 1:2649 SW ARROWHEAD RD.
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614
Practice Address - Country:US
Practice Address - Phone:785-233-0516
Practice Address - Fax:785-233-3806
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-35853-092364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100385900AMedicaid