Provider Demographics
NPI:1578664132
Name:IMBERG, WENDY C (ARNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:C
Last Name:IMBERG
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1431
Practice Address - Country:US
Practice Address - Phone:360-794-7994
Practice Address - Fax:360-805-4755
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002555363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9611518Medicaid
WAGAB08359Medicare PIN
WAS53473Medicare UPIN
WAG8878695Medicare PIN