Healthcare Provider Details

I. General information

NPI: 1942324223
Provider Name (Legal Business Name): LYNN WERNICKE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3001 SAINT KILIAN DR
CAMPBELLSPORT WI
53010-2561
US

IV. Provider business mailing address

PO BOX 223
CAMPBELLSPORT WI
53010-0223
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-5226
  • Fax:
Mailing address:
  • Phone: 920-533-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number22783-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: