Healthcare Provider Details

I. General information

NPI: 1083961833
Provider Name (Legal Business Name): HEATHER LYNN KUPHAL APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2012
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-5020
  • Fax:
Mailing address:
  • Phone: 920-926-8340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6784-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: