Provider Demographics
NPI:1245012293
Name:WENGER, ANGELA MARIE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:WENGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 SILVER LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-8459
Mailing Address - Country:US
Mailing Address - Phone:517-438-6222
Mailing Address - Fax:
Practice Address - Street 1:11600 SILVER LAKE HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-8459
Practice Address - Country:US
Practice Address - Phone:517-438-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270543NSA230TW207Q00000X, 207R00000X
MI4704270543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine