Provider Demographics
NPI:1518161058
Name:VANVALKENBURG, WENDY WAMBAUGH (RN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:WAMBAUGH
Last Name:VANVALKENBURG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21812 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-9003
Mailing Address - Country:US
Mailing Address - Phone:906-523-2448
Mailing Address - Fax:
Practice Address - Street 1:21812 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-9003
Practice Address - Country:US
Practice Address - Phone:906-523-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY569856-1163W00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINPI#1518161058OtherMESSA, BLUE CROSS BLUE SHIELD OF MICHIGNA
MINPI#1518161058Medicaid
MINPI#1518161058Medicaid