Provider Demographics
NPI:1649779091
Name:WENG, AMIE
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:WENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-747-3727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703096983164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid