Provider Demographics
NPI:1013988633
Name:WIENKE, JUDITH A (NP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:WIENKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:A
Other - Last Name:FENNESSEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-0234
Mailing Address - Fax:573-634-7423
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-634-7423
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO089694363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO215122OtherBCBS
MO428553119Medicaid
MOCD6058OtherRAILROAD GROUP
MOP00222726OtherMEDICARE RAILROAD
MO752310OtherHEALTHLINK
MO215122OtherBCBS
MOP00222726OtherMEDICARE RAILROAD