Provider Demographics
NPI:1528372828
Name:RETLICK, ANNESSA F (NP)
Entity type:Individual
Prefix:
First Name:ANNESSA
Middle Name:F
Last Name:RETLICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANNESSA
Other - Middle Name:F
Other - Last Name:LAUDONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:111 E WISCONSIN AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI154719-30363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00940026OtherMEDICARE RAILROAD
WI323500078Medicare UPIN
WIP00940026OtherMEDICARE RAILROAD