Healthcare Provider Details

I. General information

NPI: 1063728574
Provider Name (Legal Business Name): CLARE DESTREE L.P.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10732 BELGIAN DR
BRUSSELS WI
54204-9713
US

IV. Provider business mailing address

10732 BELGIAN DR
BRUSSELS WI
54204-9713
US

V. Phone/Fax

Practice location:
  • Phone: 920-619-1938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number12431-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: