Healthcare Provider Details

I. General information

NPI: 1912692872
Provider Name (Legal Business Name): HEATHER ANN GALLANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 08/11/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST STE 130
APPLETON WI
54911-3454
US

IV. Provider business mailing address

1818 N MEADE ST
APPLETON WI
54911-3454
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-1841
  • Fax:
Mailing address:
  • Phone: 920-410-7310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13823-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13823
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: