Provider Demographics
NPI:1619954179
Name:WIESEKE, ANN W (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:W
Last Name:WIESEKE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:ANN
Other - Middle Name:W
Other - Last Name:DUKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7201 E COUNTY ROAD 550 S
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-9621
Mailing Address - Country:US
Mailing Address - Phone:765-774-4309
Mailing Address - Fax:765-285-2169
Practice Address - Street 1:240 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-254-5103
Practice Address - Fax:765-741-0310
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001136A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP92202Medicare UPIN
IN466980KMedicare ID - Type Unspecified