Provider Demographics
NPI:1801219357
Name:BURNETTE, WENDY (RN:258456-COA1)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:RN:258456-COA1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-3305
Mailing Address - Country:US
Mailing Address - Phone:513-881-7189
Mailing Address - Fax:513-881-7188
Practice Address - Street 1:1490 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-3305
Practice Address - Country:US
Practice Address - Phone:513-881-7189
Practice Address - Fax:513-881-7188
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11798-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099502Medicaid
OH0200928Medicaid