Provider Demographics
NPI:1750763470
Name:WIESE, MICHELE MAE (APNP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:MAE
Last Name:WIESE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:MAE
Other - Last Name:FAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1617 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5930
Mailing Address - Country:US
Mailing Address - Phone:608-245-3094
Mailing Address - Fax:608-245-3879
Practice Address - Street 1:1617 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5930
Practice Address - Country:US
Practice Address - Phone:608-245-3094
Practice Address - Fax:608-245-3879
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI150581-30163W00000X
WI6411-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse