Provider Demographics
NPI:1528570892
Name:WENTZEL, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WENTZEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LOUVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1407 W BADDOUR PKWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-444-6203
Mailing Address - Fax:
Practice Address - Street 1:1407 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-444-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC327683363A00000X
TN3405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant