Provider Demographics
NPI:1548417322
Name:WENCK, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WENCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:WENCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:8040 CLEARVISTA PKWY STE 570
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4673
Mailing Address - Country:US
Mailing Address - Phone:317-621-2520
Mailing Address - Fax:317-621-2580
Practice Address - Street 1:8040 CLEARVISTA PKWY STE 570
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4673
Practice Address - Country:US
Practice Address - Phone:317-621-2520
Practice Address - Fax:317-621-2580
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001523A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner