Provider Demographics
NPI:1154029858
Name:WENGS, AMANDA L (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WENGS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4807
Mailing Address - Country:US
Mailing Address - Phone:575-546-5951
Mailing Address - Fax:575-546-5994
Practice Address - Street 1:13A SAN MARCOS LOOP
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-7083
Practice Address - Country:US
Practice Address - Phone:505-986-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML18298164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse