Provider Demographics
NPI:1629044656
Name:TEETOR, WENDY KIRSTEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:KIRSTEN
Last Name:TEETOR
Suffix:
Gender:F
Credentials:PT
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:16120 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2049
Practice Address - Country:US
Practice Address - Phone:402-354-0410
Practice Address - Fax:402-354-0415
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026056700Medicaid
IA1629044656Medicaid
NE1006252200Medicaid
NE1002589600Medicaid
NE10025895900Medicaid
NE10025941700Medicaid
NE10025896100Medicaid
NE1006252200Medicaid