Basic Information
| Provider Information | |||||||||
| NPI: | 1225238900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENZEL | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN STREET | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551122912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267575 | ||||||||
| FaxNumber: | 6124542430 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F402151 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | SP009464 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 6287 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1225238900 | 05 | MN | MEDICAID | 04763420 | 05 | NY | MEDICAID |