Provider Demographics
NPI:1356431894
Name:WACKER, DONNA M (FNP-C)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:M
Last Name:WACKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:TURTLE LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58575-9661
Mailing Address - Country:US
Mailing Address - Phone:701-628-2505
Mailing Address - Fax:701-628-3274
Practice Address - Street 1:615 6 ST SE
Practice Address - Street 2:MOUNTRAIL COUNTY MEDICAL CENTER
Practice Address - City:STANLEY
Practice Address - State:ND
Practice Address - Zip Code:58784
Practice Address - Country:US
Practice Address - Phone:701-628-2505
Practice Address - Fax:701-628-3274
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19843Medicaid
ND25650Medicare ID - Type UnspecifiedMEDICARE ID