Provider Demographics
NPI:1306948245
Name:GRAVELLE, WENDY AMANDA (CRNA)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:AMANDA
Last Name:GRAVELLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:WENDY
Other - Middle Name:AMANDA
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:13436 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482
Mailing Address - Country:US
Mailing Address - Phone:218-632-5989
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST NORTH
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482
Practice Address - Country:US
Practice Address - Phone:218-631-3510
Practice Address - Fax:218-631-7496
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1540705367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered