Healthcare Provider Details

I. General information

NPI: 1902391410
Provider Name (Legal Business Name): JENNAH A.L. HAQUE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA A LANDWEHR RN

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 DEVELOPMENT DR
GREEN BAY WI
54311-4240
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-6868
  • Fax: 920-338-6869
Mailing address:
  • Phone: 920-445-7226
  • Fax: 920-445-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8713-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number223532-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: