Provider Demographics
NPI:1043844103
Name:WENDLANDT, AUTUMN BROOKE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:BROOKE
Last Name:WENDLANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2677 HUMBOLDT RD APT 16
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8442
Mailing Address - Country:US
Mailing Address - Phone:920-918-7636
Mailing Address - Fax:
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-458-6527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI249764-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse