Healthcare Provider Details

I. General information

NPI: 1598272809
Provider Name (Legal Business Name): ELLEN WENDLANDT LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 DRURY PL
FOND DU LAC WI
54935-4721
US

IV. Provider business mailing address

PO BOX 104
BROWNSVILLE WI
53006-0104
US

V. Phone/Fax

Practice location:
  • Phone: 920-979-1987
  • Fax:
Mailing address:
  • Phone: 920-970-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number321214
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: