Provider Demographics
NPI:1134360308
Name:WENDELA, JILL (RPN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WENDELA
Suffix:
Gender:F
Credentials:RPN
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 21
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAMS
Mailing Address - State:NY
Mailing Address - Zip Code:14812-0021
Mailing Address - Country:US
Mailing Address - Phone:607-535-8140
Mailing Address - Fax:
Practice Address - Street 1:106 S PERRY ST
Practice Address - Street 2:STE 4
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1615
Practice Address - Country:US
Practice Address - Phone:607-535-8140
Practice Address - Fax:607-535-8157
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY533970163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY533970Medicaid