Provider Demographics
NPI:1629035126
Name:WINDHAM, WENDY A (CRNA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:A
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:A
Other - Last Name:WINDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:400 N EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2510
Mailing Address - Country:US
Mailing Address - Phone:334-347-0584
Mailing Address - Fax:
Practice Address - Street 1:400 N EDWARDS ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2510
Practice Address - Country:US
Practice Address - Phone:334-347-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-053949367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009973270Medicaid
AL009973270Medicaid