Provider Demographics
NPI:1265199624
Name:WENTLANDT, MIRANDA NICOLE (MSM, LM, CPM)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:NICOLE
Last Name:WENTLANDT
Suffix:
Gender:F
Credentials:MSM, LM, CPM
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:NICOLE
Other - Last Name:RASMUSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:134 MADRONA DR NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-5927
Mailing Address - Country:US
Mailing Address - Phone:425-495-3399
Mailing Address - Fax:
Practice Address - Street 1:20696 BOND ROAD NE
Practice Address - Street 2:BLDG C, SUITE 110
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9025
Practice Address - Country:US
Practice Address - Phone:360-779-0004
Practice Address - Fax:360-938-8791
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife