Provider Demographics
NPI:1942324223
Name:WERNICKE, LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:WERNICKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-0223
Mailing Address - Country:US
Mailing Address - Phone:920-533-5226
Mailing Address - Fax:
Practice Address - Street 1:W3001 SAINT KILIAN DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-2561
Practice Address - Country:US
Practice Address - Phone:920-533-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22783-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39878200Medicaid