Provider Demographics
NPI:1750799482
Name:WENCL, COREY (LAT)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WENCL
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4863
Mailing Address - Country:US
Mailing Address - Phone:920-602-6935
Mailing Address - Fax:
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI819-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer