Provider Demographics
NPI:1104010404
Name:ROSE, WENDY (RN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 GENTRY AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-2949
Mailing Address - Country:US
Mailing Address - Phone:651-779-0887
Mailing Address - Fax:
Practice Address - Street 1:1300 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-9395
Practice Address - Country:US
Practice Address - Phone:715-684-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR118991-7163W00000X
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38311100Medicaid