Provider Demographics
NPI:1336133727
Name:WEISENSEL, NICOLETTE ELLA (MD)
Entity Type:Individual
Prefix:MS
First Name:NICOLETTE
Middle Name:ELLA
Last Name:WEISENSEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SHERMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1960
Mailing Address - Country:US
Mailing Address - Phone:920-568-5000
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:129 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3334
Practice Address - Country:US
Practice Address - Phone:920-262-4800
Practice Address - Fax:920-262-4813
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43679-202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34591800Medicaid
E50016Medicare UPIN
WI34591800Medicaid