Provider Demographics
NPI:1720342348
Name:WENNINGER, JENNIFER NICOLE (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WENNINGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:DELFOSSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3916 N INTERTECH CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6957
Mailing Address - Country:US
Mailing Address - Phone:920-996-1000
Mailing Address - Fax:920-997-8302
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6957
Practice Address - Country:US
Practice Address - Phone:920-996-1000
Practice Address - Fax:920-997-8302
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2935-23363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002150292Medicare Oscar/Certification