Provider Demographics
NPI:1700318284
Name:ROTT, WANDA (RN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ROTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9167 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N9167 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-2211
Practice Address - Country:US
Practice Address - Phone:262-363-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122214163W00000X
WIL-31815163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI163WL0100XMedicaid