Provider Demographics
NPI:1538353982
Name:WISCONSIN MEDICAID
Entity type:Organization
Organization Name:WISCONSIN MEDICAID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LEI
Authorized Official - Last Name:SELLIER
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:920-727-0441
Mailing Address - Street 1:979 HIGHLAND PARK RD
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1320
Mailing Address - Country:US
Mailing Address - Phone:920-727-0441
Mailing Address - Fax:
Practice Address - Street 1:1528 REMINGTON RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1696
Practice Address - Country:US
Practice Address - Phone:920-729-9887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric