Basic Information
| Provider Information | |||||||||
| NPI: | 1386806677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICHTENDAHL | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | UMC STONY BRK | ||||||||
| Address2: | HSC T-16-080 | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314443575 | ||||||||
| FaxNumber: | 6314441054 | ||||||||
| Practice Location | |||||||||
| Address1: | UMC STONY BRK | ||||||||
| Address2: | HSC T-16-080 | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314443575 | ||||||||
| FaxNumber: | 6314441054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | F301619 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | F301619 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.