Healthcare Provider Details

I. General information

NPI: 1205763463
Provider Name (Legal Business Name): TYLER WENDELBORN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-5961
  • Fax:
Mailing address:
  • Phone: 920-674-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: