Healthcare Provider Details

I. General information

NPI: 1922773217
Provider Name (Legal Business Name): JENNIFER GWIAZDA APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

13741 88TH AVE
CHIPPEWA FALLS WI
54729-5940
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4402
  • Fax: 833-485-5165
Mailing address:
  • Phone: 715-563-2366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11167
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: