Provider Demographics
NPI:1174591523
Name:PLUM, WENDY JO (CRNA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:JO
Last Name:PLUM
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 1:3009 S JOHN REDDITT
Mailing Address - Street 2:#168
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901
Mailing Address - Country:US
Mailing Address - Phone:808-222-1712
Mailing Address - Fax:
Practice Address - Street 1:3009 S JOHN REDDITT DR # 168
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5661
Practice Address - Country:US
Practice Address - Phone:808-222-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN243133367500000X
FLARNP 2721072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101120525Medicaid
FLG3986YMedicare PIN
PA085610Medicare PIN
PA101120525Medicaid