Provider Demographics
NPI:1194077644
Name:DUTCHER, WENDY RENEE (RN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:RENEE
Last Name:DUTCHER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TEEGARDEN ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3175
Mailing Address - Country:US
Mailing Address - Phone:219-326-0043
Mailing Address - Fax:219-326-8909
Practice Address - Street 1:400 TEEGARDEN ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3175
Practice Address - Country:US
Practice Address - Phone:219-326-0043
Practice Address - Fax:219-326-8909
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160815A363L00000X, 163W00000X
IN71004235A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN25-9860003OtherMEDICARE PTAN
IN201149460Medicaid
IN151020022OtherMEDICARE PTAN