1265199624 NPI number — MRS. MIRANDA NICOLE WENTLANDT MSM, LM, CPM

Table of content: MRS. MIRANDA NICOLE WENTLANDT MSM, LM, CPM (NPI 1265199624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265199624 NPI number — MRS. MIRANDA NICOLE WENTLANDT MSM, LM, CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENTLANDT
Provider First Name:
MIRANDA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSM, LM, CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RASMUSSON
Provider Other First Name:
MIRANDA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265199624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 MADRONA DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GIG HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98335-5927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-495-3399
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20696 BOND ROAD NE
Provider Second Line Business Practice Location Address:
BLDG C, SUITE 110
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370-9025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-779-0004
Provider Business Practice Location Address Fax Number:
360-938-8791
Provider Enumeration Date:
11/19/2021

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: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com