Provider Demographics
NPI:1255426789
Name:WENTLAND, JUDY YAKICH (NP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:YAKICH
Last Name:WENTLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2643 LIBAL ST
Mailing Address - Street 2:STE C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2885
Mailing Address - Country:US
Mailing Address - Phone:920-388-0560
Mailing Address - Fax:
Practice Address - Street 1:1039 WEST MASON STREET
Practice Address - Street 2:EXECUTIVE OFFICE SUITES
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-965-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI911033363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health