Provider Demographics
NPI:1548625106
Name:WINGART, BETH
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WINGART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 CHAPIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2000
Mailing Address - Country:US
Mailing Address - Phone:517-499-0001
Mailing Address - Fax:
Practice Address - Street 1:1703 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-2000
Practice Address - Country:US
Practice Address - Phone:517-499-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0022688172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker