Provider Demographics
NPI:1003363482
Name:WIERSEMA, WENDY (LPN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WIERSEMA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25559 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:CHADWICK
Mailing Address - State:IL
Mailing Address - Zip Code:61014-9289
Mailing Address - Country:US
Mailing Address - Phone:815-499-9072
Mailing Address - Fax:
Practice Address - Street 1:325 IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-284-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043037853164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse