Provider Demographics
NPI:1013170653
Name:WENSTROM, WILLIAM (ACNP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WENSTROM
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:
Practice Address - Street 1:3615 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-546-3257
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851481363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care