Healthcare Provider Details

I. General information

NPI: 1629757448
Provider Name (Legal Business Name): KERI GREGG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N WILSON ST
FREDONIA WI
53021-9482
US

IV. Provider business mailing address

2675 BACKWOODS RD
SLINGER WI
53086-9776
US

V. Phone/Fax

Practice location:
  • Phone: 262-689-3172
  • Fax:
Mailing address:
  • Phone: 262-370-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1106245-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: