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NPI Code Detail

MEDICARE: MS. JILL KOCH WANGGAARD NP

MEDICARE: MS. JILL KOCH WANGGAARD NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner74115WI
2363LF0000XFamily Nurse Practitioner74115-030WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1396734034
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JILL KOCH WANGGAARD NP
Provider Business Mailing Address
First Line : 3301 W FOREST HOME AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53215-2843
Country : US
Telephone Number : 262-884-4088
Fax Number : 262-884-4078
Provider Business Practice Location Address
First Line : 8400 WASHINGTON AVE
Second Line :
City : MOUNT PLEASANT
State : WI
Zip : 53406-3735
Country : US
Telephone Number : 262-884-4088
Fax Number : 262-884-4078
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/15/2005
Last Update Date : 11/23/2021

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