Provider Demographics
NPI:1720360894
Name:WAASDORP, WENDY LORRAINE (RN,BSN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LORRAINE
Last Name:WAASDORP
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1221
Mailing Address - Country:US
Mailing Address - Phone:315-502-4367
Mailing Address - Fax:
Practice Address - Street 1:439 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-2062
Practice Address - Country:US
Practice Address - Phone:315-332-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY407646163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse