Provider Demographics
NPI:1528219680
Name:SMITH, WENDALEE K (ARNP)
Entity Type:Individual
Prefix:MISS
First Name:WENDALEE
Middle Name:K
Last Name:SMITH
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 1:1825 LOGAN AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1916
Mailing Address - Country:US
Mailing Address - Phone:319-235-3697
Mailing Address - Fax:319-235-3844
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3697
Practice Address - Fax:319-235-3844
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA107822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1528219680Medicaid
IA1528219680Medicaid