Provider Demographics
NPI:1770008492
Name:EVENSON, JUDITH ANN (APNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:EVENSON
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 1:1155 N MAYFAIR ROAD
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3464
Mailing Address - Country:US
Mailing Address - Phone:414-955-8990
Mailing Address - Fax:414-955-6299
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:262-366-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7811-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770008492Medicaid