Provider Demographics
NPI:1770760605
Name:WAHL, RONICA MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:RONICA
Middle Name:MARIE
Last Name:WAHL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:RONICA
Other - Middle Name:MARIE
Other - Last Name:GERMAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:29494 170TH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7570
Mailing Address - Country:US
Mailing Address - Phone:218-844-5890
Mailing Address - Fax:
Practice Address - Street 1:665 3RD ST SW
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1137
Practice Address - Country:US
Practice Address - Phone:218-844-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 156674-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily