Provider Demographics
NPI:1952311219
Name:KOVICH, WENDY JO
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:JO
Last Name:KOVICH
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 1:9861 ILEX ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5445
Mailing Address - Country:US
Mailing Address - Phone:763-205-3708
Mailing Address - Fax:
Practice Address - Street 1:255 SMITH AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2572
Practice Address - Country:US
Practice Address - Phone:651-726-2753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 113682-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse