Provider Demographics
NPI:1831402734
Name:TALLEN-WHITED, AEMELIA ANNE (CPNP)
Entity type:Individual
Prefix:
First Name:AEMELIA
Middle Name:ANNE
Last Name:TALLEN-WHITED
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-653-5437
Mailing Address - Fax:262-656-3415
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 1040
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-653-5437
Practice Address - Fax:262-656-3415
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4695-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4695-33OtherLICENSE
WI1831402734Medicaid