Provider Demographics
NPI:1760592711
Name:WESSENDORF, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:WESSENDORF
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 1:1717 SHAFFER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 S US 131
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093
Practice Address - Country:US
Practice Address - Phone:269-286-7070
Practice Address - Fax:269-286-7071
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704165487363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S96720Medicare UPIN