Basic Information
| Provider Information | |||||||||
| NPI: | 1265655732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEDERSTADT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3803 SPRING ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534051660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626878260 | ||||||||
| FaxNumber: | 2626878729 | ||||||||
| Practice Location | |||||||||
| Address1: | 3803 SPRING ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534051660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626878260 | ||||||||
| FaxNumber: | 2626878729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2059-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43999000 | 05 | WI | MEDICAID |