Provider Demographics
NPI:1497599690
Name:WENGER, MICHAEL JOHN (RN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:WENGER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-3639
Mailing Address - Country:US
Mailing Address - Phone:541-817-6194
Mailing Address - Fax:
Practice Address - Street 1:605 WOODLAND SQUARE LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1045
Practice Address - Country:US
Practice Address - Phone:306-754-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61104015163WP0808X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health