Provider Demographics
NPI:1447364906
Name:EASTON, WENDY LYNN (NP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LYNN
Last Name:EASTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 TWENTY-FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316
Mailing Address - Country:US
Mailing Address - Phone:810-790-1615
Mailing Address - Fax:
Practice Address - Street 1:46960 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-4378
Practice Address - Country:US
Practice Address - Phone:586-726-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704112593363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-5198292Medicaid
MI11-4976623Medicaid
MI10-5198318Medicaid
11712518OtherCAQH
MI10-4827712Medicaid
MI10-5198318Medicaid
MI10-4827712Medicaid
MIN87440027Medicare ID - Type UnspecifiedPEC SJMM
MIP34780099Medicare PIN
P40540034Medicare PIN