Basic Information
| Provider Information | |||||||||
| NPI: | 1366744708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERRY | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | WETZEL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WETZEL | ||||||||
| OtherFirstName: | DONNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1660 S STAPLES ST | ||||||||
| Address2: | STE 150 | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784043173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618008155 | ||||||||
| FaxNumber: | 3618822590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 S STAPLES ST | ||||||||
| Address2: | STE 150 | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784043173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618008155 | ||||||||
| FaxNumber: | 3618822590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2010 | ||||||||
| LastUpdateDate: | 02/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP125156 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 396630YLPS | 01 | TX | WNI PTAN | OTHER | 348993201 | 05 | TX | MEDICAID |