Provider Demographics
NPI:1558062299
Name:WENGERT, KATELAN MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:KATELAN
Middle Name:MARIE
Last Name:WENGERT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BACA RD
Mailing Address - Street 2:
Mailing Address - City:CUBERO
Mailing Address - State:NM
Mailing Address - Zip Code:87014-0106
Mailing Address - Country:US
Mailing Address - Phone:505-290-9213
Mailing Address - Fax:
Practice Address - Street 1:28 BACA RD
Practice Address - Street 2:
Practice Address - City:CUBERO
Practice Address - State:NM
Practice Address - Zip Code:87014-0106
Practice Address - Country:US
Practice Address - Phone:505-290-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM60445164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse