Provider Demographics
NPI:1679888085
Name:WENDA, WALTER THOMAS (RN)
Entity type:Individual
Prefix:PROF
First Name:WALTER
Middle Name:THOMAS
Last Name:WENDA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3568
Mailing Address - Country:US
Mailing Address - Phone:651-464-3966
Mailing Address - Fax:
Practice Address - Street 1:5700 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3568
Practice Address - Country:US
Practice Address - Phone:651-464-3966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-084696-3163WM0705X, 163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health