Provider Demographics
NPI:1790069599
Name:MANKE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MANKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:MAIL ROUTE MN 008-B213
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:920-574-1255
Mailing Address - Fax:
Practice Address - Street 1:N9168 CHERRY MEADOW DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4681
Practice Address - Country:US
Practice Address - Phone:920-284-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI147545-30363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790069599Medicaid
WI1790069599Medicaid