Healthcare Provider Details

I. General information

NPI: 1053335174
Provider Name (Legal Business Name): DIANE L WENDLAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6408 COPPS AVE
MONONA WI
53716
US

IV. Provider business mailing address

202 S PARK ST
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-3000
  • Fax: 608-417-3100
Mailing address:
  • Phone: 608-417-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28643-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: