Provider Demographics
NPI:1063433118
Name:WENKE, MARY L (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:WENKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91345
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-0345
Mailing Address - Country:US
Mailing Address - Phone:502-896-6428
Mailing Address - Fax:
Practice Address - Street 1:4004 DUPONT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4819
Practice Address - Country:US
Practice Address - Phone:502-896-6428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1631A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY73474570Medicaid
KY73474570Medicaid