Provider Demographics
NPI:1538736350
Name:WYCKLENDT, THERESA L (APNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:WYCKLENDT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:PALMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-219-2000
Mailing Address - Fax:
Practice Address - Street 1:2514 S 102ND ST STE 160
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2142
Practice Address - Country:US
Practice Address - Phone:414-255-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11060-033363L00000X
WI1716711363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100174297Medicaid