Basic Information
| Provider Information | |||||||||
| NPI: | 1881683704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENZKE | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 MEIJER DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198431362 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 MEIJER DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198431362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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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 | 363L00000X | NP06047 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2518565 | 05 | OH | MEDICAID |