Provider Demographics
NPI:1720063654
Name:MUMA, WENDY (FNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MUMA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 12 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-9754
Mailing Address - Country:US
Mailing Address - Phone:616-391-8470
Mailing Address - Fax:616-391-8495
Practice Address - Street 1:2111 12 MILE RD NW
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-9754
Practice Address - Country:US
Practice Address - Phone:616-391-8470
Practice Address - Fax:616-391-8495
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704194182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4493529Medicaid
MIS85979Medicare UPIN
MI0M98130007Medicare PIN