Provider Demographics
NPI:1740426972
Name:WIENEKE, MICHELLE CHERIE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CHERIE
Last Name:WIENEKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 WHIPPOORWILL LN
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-8481
Mailing Address - Country:US
Mailing Address - Phone:479-481-6599
Mailing Address - Fax:479-413-8927
Practice Address - Street 1:1620 WHIPPOORWILL LN
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72713-8481
Practice Address - Country:US
Practice Address - Phone:479-481-6599
Practice Address - Fax:479-413-8927
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP000182363L00000X
ARA03213363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177309758Medicaid
AR5V039Medicare PIN