Healthcare Provider Details

I. General information

NPI: 1073354262
Provider Name (Legal Business Name): KRISTEN ANN GENDRON APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 WAUBE LN
GREEN BAY WI
54304-5521
US

IV. Provider business mailing address

1118 WESTWOOD DR
DE PERE WI
54115-1015
US

V. Phone/Fax

Practice location:
  • Phone: 920-548-9500
  • Fax: 920-433-6788
Mailing address:
  • Phone: 906-221-6285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15402-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: