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General NPI Number Information
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NPI Number | 1750763470
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Entity Type | Individual
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Provider Name | MICHELE MAE WIESE APNP
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Gender | Female
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Dates
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Enumeration Date | 06/19/2015
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Last Update Date | 06/05/2020
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Provider Practice Location Address
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Address Line | 1617 SHERMAN AVE
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City | MADISON
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State | WI
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Zip | 53704-5930
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Country | US
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Telephone | 608-245-3094
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Fax | 608-245-3879
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Provider Business Mailing Address
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Address Line | 1617 SHERMAN AVE
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City | MADISON
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State | WI
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Zip | 53704-5930
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Country | US
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Telephone | 608-245-3094
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Fax | 608-245-3879
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 150581-30
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 6411-33
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License Number State | WI
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