Provider Demographics
NPI:1336453315
Name:PETINGA, JANELLE MARIE (ANP-BC)
Entity type:Individual
Prefix:MS
First Name:JANELLE
Middle Name:MARIE
Last Name:PETINGA
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:MS
Other - First Name:JANELLE
Other - Middle Name:MARIE
Other - Last Name:KUBISIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-805-7342
Mailing Address - Fax:414-805-7919
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-805-7342
Practice Address - Fax:414-805-7919
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2009006582363LP2300X
WI4113-033363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336453315Medicaid
WI1336453315Medicaid