Provider Demographics
NPI:1801294087
Name:VANWYNGARDEN, BETH (LAC, MAOM)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:VANWYNGARDEN
Suffix:
Gender:F
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13487
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1487
Mailing Address - Country:US
Mailing Address - Phone:503-798-2918
Mailing Address - Fax:
Practice Address - Street 1:4570 W 77TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5008
Practice Address - Country:US
Practice Address - Phone:612-886-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-20
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1747171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist