Provider Demographics
NPI:1851714901
Name:TITSWORTH, WENDY LEIGH (NP-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LEIGH
Last Name:TITSWORTH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6092 FENTON RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4761
Mailing Address - Country:US
Mailing Address - Phone:810-239-4697
Mailing Address - Fax:810-239-4553
Practice Address - Street 1:6092 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4761
Practice Address - Country:US
Practice Address - Phone:810-239-4697
Practice Address - Fax:810-239-4553
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704238065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI462816109OtherEIN