Provider Demographics
NPI:1407852916
Name:MENNEN, JULIA NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:NICOLE
Last Name:MENNEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:NICOLE
Other - Last Name:MICKEY, REWOLINSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1032 S CESAR E CHAVEZ DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2203
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:414-672-4265
Practice Address - Street 1:1032 S CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2203
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-672-4265
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39280350003OtherBC/BS
WI41972400Medicaid
WIMM0911607OtherDEA
WI521805Medicare Oscar/Certification
WI521830Medicare Oscar/Certification
WIP85834Medicare UPIN
WI0064:01545Medicare PIN