Provider Demographics
NPI:1942344239
Name:WENDELL, NATHAN S
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:S
Last Name:WENDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-234-8572
Practice Address - Street 1:1072 S DIXIE BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1103
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:270-234-8572
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2007-08103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY000000548926OtherANTHEM
KY0762346Medicare PIN
KY000000548926OtherANTHEM
KY00206004Medicare PIN
KY0974719Medicare PIN
KY00200006Medicare PIN
KY0762249Medicare PIN
KY0763.546Medicare PIN
KY00199006Medicare PIN
KY00201006Medicare PIN
KY00207004Medicare PIN
KY30605018Medicaid