Provider Demographics
NPI:1649063199
Name:WALL, JILL ANN (FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:WALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ANN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W169N10790 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-3970
Mailing Address - Country:US
Mailing Address - Phone:414-345-8504
Mailing Address - Fax:
Practice Address - Street 1:245 REGENCY CT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-6167
Practice Address - Country:US
Practice Address - Phone:262-357-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16839-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty