1306948245 NPI number — MRS. WENDY AMANDA GRAVELLE CRNA

Table of content: MRS. WENDY AMANDA GRAVELLE CRNA (NPI 1306948245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306948245 NPI number — MRS. WENDY AMANDA GRAVELLE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVELLE
Provider First Name:
WENDY
Provider Middle Name:
AMANDA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEYER
Provider Other First Name:
WENDY
Provider Other Middle Name:
AMANDA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306948245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13436 COUNTY ROAD 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADENA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-632-5989
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 JEFFERSON ST NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADENA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-631-3510
Provider Business Practice Location Address Fax Number:
218-631-7496
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R1540705 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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