Basic Information
| Provider Information | |||||||||
| NPI: | 1760451348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4685 FOREST AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452123359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135695027 | ||||||||
| FaxNumber: | 5135695199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3440 BURNET AVE | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452292833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137515900 | ||||||||
| FaxNumber: | 5134874596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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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 | NM05810 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 2260977 | 05 | OH | MEDICAID | 200409830B | 05 | IN | MEDICAID | 78008661 | 05 | KY | MEDICAID | 200409830C | 05 | IN | MEDICAID | 200409830A | 05 | IN | MEDICAID |