Provider Demographics
NPI:1669580262
Name:WIDENER, WALLETTE GWEN (NP)
Entity type:Individual
Prefix:
First Name:WALLETTE
Middle Name:GWEN
Last Name:WIDENER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6602 WATERS AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2716
Mailing Address - Country:US
Mailing Address - Phone:912-354-7676
Mailing Address - Fax:912-790-6456
Practice Address - Street 1:6602 WATERS AVE BLDG C
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2716
Practice Address - Country:US
Practice Address - Phone:912-354-7676
Practice Address - Fax:912-790-6456
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA410170417AMedicaid
GAQ38524Medicare UPIN
GA410170417AMedicaid