Healthcare Provider Details

I. General information

NPI: 1194342709
Provider Name (Legal Business Name): ANNA JANE GAUTHIER APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA JANE WILHELMS

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-6877
  • Fax: 920-738-4792
Mailing address:
  • Phone: 920-454-4101
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10286
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number229918
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: