Healthcare Provider Details

I. General information

NPI: 1811188683
Provider Name (Legal Business Name): JENNIFER L REICHARDT APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER L MATTIOLI APNP

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W5282 AMY AVE
APPLETON WI
54915-7233
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-358-1900
  • Fax:
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3157
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3157
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: