Provider Demographics
NPI:1588055107
Name:PDN
Entity type:Organization
Organization Name:PDN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-458-3179
Mailing Address - Street 1:708 HAWTHORNE AVE UPPR
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1734
Mailing Address - Country:US
Mailing Address - Phone:414-458-3179
Mailing Address - Fax:
Practice Address - Street 1:708 HAWTHORNE AVE UPPR
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-1734
Practice Address - Country:US
Practice Address - Phone:414-458-3179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16513630314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility