Healthcare Provider Details

I. General information

NPI: 1154192623
Provider Name (Legal Business Name): ALEXANDRA L WIDENSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 W LINCOLN AVE
MILWAUKEE WI
53227-1133
US

IV. Provider business mailing address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

V. Phone/Fax

Practice location:
  • Phone: 800-767-4411
  • Fax:
Mailing address:
  • Phone: 262-646-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number253228-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15724-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: