Healthcare Provider Details

I. General information

NPI: 1982133807
Provider Name (Legal Business Name): PA KOU VANG THAO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W WISCONSIN AVE
APPLETON WI
54911-4337
US

IV. Provider business mailing address

315 BIRCH ST
HORTONVILLE WI
54944-9355
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-6304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7641-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: