Basic Information
| Provider Information | |||||||||
| NPI: | 1659356269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENTE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085834649 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085834649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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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 | 367A00000X | 210876 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0367940 | 05 | MA | MEDICAID |