Healthcare Provider Details

I. General information

NPI: 1164045092
Provider Name (Legal Business Name): ROBYN W LAURITSEN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 E EVERGREEN DR
APPLETON WI
54913-8910
US

IV. Provider business mailing address

2575 E EVERGREEN DR
APPLETON WI
54913-8910
US

V. Phone/Fax

Practice location:
  • Phone: 920-404-2240
  • Fax:
Mailing address:
  • Phone: 920-404-2240
  • Fax: 920-404-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10179-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number193403-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: