Healthcare Provider Details

I. General information

NPI: 1578100772
Provider Name (Legal Business Name): AMY DENNEAU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W10237 LAKE EMILY RD
FOX LAKE WI
53933
US

IV. Provider business mailing address

226 E MONROE AVE
HARTFORD WI
53027-2416
US

V. Phone/Fax

Practice location:
  • Phone: 920-928-6960
  • Fax:
Mailing address:
  • Phone: 414-617-0724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9767
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: