Provider Demographics
NPI:1780261636
Name:SAMPLE, WENDY JANE
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:JANE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22055 TENNY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2741
Mailing Address - Country:US
Mailing Address - Phone:313-930-4813
Mailing Address - Fax:
Practice Address - Street 1:7800 W OUTER DR STE 203
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3459
Practice Address - Country:US
Practice Address - Phone:313-259-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator