Provider Demographics
NPI:1689629214
Name:MANDEL, TRUDY A (RN)
Entity Type:Individual
Prefix:MRS
First Name:TRUDY
Middle Name:A
Last Name:MANDEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRUDY
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024
Mailing Address - Country:US
Mailing Address - Phone:262-375-4471
Mailing Address - Fax:
Practice Address - Street 1:616 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:414-915-3066
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50665030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39859400Medicaid