Healthcare Provider Details

I. General information

NPI: 1427615004
Provider Name (Legal Business Name): HEIDI WURTINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10424 W BLUEMOUND RD
MILWAUKEE WI
53226-4331
US

IV. Provider business mailing address

N66W30637 RED FOX RUN
HARTLAND WI
53029-9187
US

V. Phone/Fax

Practice location:
  • Phone: 414-244-9844
  • Fax: 414-877-1104
Mailing address:
  • Phone: 414-418-6848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12568-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: