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General NPI Number Information
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NPI Number | 1881334233
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Entity Type | Individual
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Provider Name | NICOLE ELYSE WUNDERLICH MD
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Gender | Female
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Dates
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Enumeration Date | 03/31/2022
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 4300 MARKET PTE DR STE 100
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City | BLOOMINGTON
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State | MN
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Zip | 55435-5435
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Country | US
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Telephone | 952-767-4574
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Fax |
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Provider Business Mailing Address
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Address Line | 1041 GRETCHEN LN
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City | GRAND LEDGE
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State | MI
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Zip | 48837-1874
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Country | US
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Telephone | 763-331-5258
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Fax |
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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 | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number | 4351049263APP22
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 4351049263APP22
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License Number State | MI
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