Provider Demographics
NPI:1427429729
Name:VITEK SEMRAD, JENNIFER K (APNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:VITEK SEMRAD
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8475
Mailing Address - Country:US
Mailing Address - Phone:262-928-1900
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8475
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-013533363LF0000X
IL041403514163W00000X
WI6704363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400305733Medicare PIN
WI000068375Medicare PIN