Provider Demographics
NPI:1790979219
Name:WENTLING, ELIZABETH GILLUM (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:GILLUM
Last Name:WENTLING
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:WENTLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:
Practice Address - Street 1:408 N MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-584-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249005367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL033426000Medicaid
FLG0084OtherBCBS
G0084TMedicare PIN
FL033426000Medicaid
FLG0084WMedicare PIN