Healthcare Provider Details

I. General information

NPI: 1639948466
Provider Name (Legal Business Name): CASSANDRA EVON WEISNICHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

IV. Provider business mailing address

313 ADAMS ST
ROSENDALE WI
54974-9745
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5534
  • Fax:
Mailing address:
  • Phone: 414-828-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14920-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: