Provider Demographics
NPI:1710402714
Name:WIEDEMEIER, OLENA V (APNP)
Entity Type:Individual
Prefix:
First Name:OLENA
Middle Name:V
Last Name:WIEDEMEIER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:2741 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3833
Practice Address - Country:US
Practice Address - Phone:715-732-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7853-33363LF0000X
MI4704317913363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
20117009758OtherANCC
WI7853-33OtherWISCONSIN DSPS BOARD OF NURSING