Provider Demographics
NPI:1912258716
Name:WENTWORTH, PAMELA R (RN)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:R
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:IA
Mailing Address - Zip Code:45402-2715
Mailing Address - Country:US
Mailing Address - Phone:937-461-3450
Mailing Address - Fax:937-461-9584
Practice Address - Street 1:349 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:IA
Practice Address - Zip Code:45402
Practice Address - Country:US
Practice Address - Phone:937-461-3450
Practice Address - Fax:937-461-9584
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH278653163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH278653OtherRN