Provider Demographics
NPI:1114039351
Name:WOLF, BECKYSUE (APNP)
Entity Type:Individual
Prefix:MS
First Name:BECKYSUE
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:BECKYSUE
Other - Middle Name:
Other - Last Name:BYNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:3021 VOYAGER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8303
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4705
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI99886-030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43979500Medicaid
P24073Medicare UPIN
WI43979500Medicaid