Basic Information
| Provider Information | |||||||||
| NPI: | 1053590323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENDEL | ||||||||
| FirstName: | BONITA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | APNP/BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | ATTN: CSMCP CLINIC CREDENTIALING | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623761934 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2061 CHEYENNE CT | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530249368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623761934 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3244 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 36050600 | 05 | WI | MEDICAID |