Provider Demographics
NPI:1689360240
Name:WONENBERG, ERIN KATHERINE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KATHERINE
Last Name:WONENBERG
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 W VERBENA DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6129
Mailing Address - Country:US
Mailing Address - Phone:208-409-7396
Mailing Address - Fax:
Practice Address - Street 1:1920 W VERBENA DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6129
Practice Address - Country:US
Practice Address - Phone:208-409-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID75964363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care