Healthcare Provider Details

I. General information

NPI: 1801482294
Provider Name (Legal Business Name): CHADBOURNE WALTERS APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2020
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE STE 111
APPLETON WI
54913-7862
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE STE 111
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-6611
  • Fax: 920-731-6732
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10333
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10333-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: