Provider Demographics
NPI:1538736350
Name:WYCKLENDT, THERESA L (APNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:WYCKLENDT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:PALMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 40412
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1255
Mailing Address - Country:US
Mailing Address - Phone:312-818-4650
Mailing Address - Fax:855-618-2629
Practice Address - Street 1:1000 BURR RIDGE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0864
Practice Address - Country:US
Practice Address - Phone:312-818-4650
Practice Address - Fax:855-618-2629
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11060-033363L00000X
WI1716711363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100174297Medicaid