Provider Demographics
NPI:1558428219
Name:WENK, NANCY MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MARIE
Last Name:WENK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 OWLS WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-2541
Mailing Address - Country:US
Mailing Address - Phone:321-264-0383
Mailing Address - Fax:
Practice Address - Street 1:317 RIVEREDGE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7988
Practice Address - Country:US
Practice Address - Phone:321-264-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73996OtherBLUE CROSS BLUE SHIELD