Provider Demographics
NPI:1053590323
Name:WENDEL, BONITA J (APNP/BC)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:J
Last Name:WENDEL
Suffix:
Gender:F
Credentials:APNP/BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-376-1934
Mailing Address - Fax:
Practice Address - Street 1:2061 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9368
Practice Address - Country:US
Practice Address - Phone:262-376-1934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3244363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36050600Medicaid
WI002546210Medicare PIN
WI36050600Medicaid