Healthcare Provider Details

I. General information

NPI: 1750125514
Provider Name (Legal Business Name): SARA DETTLAFF APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE FL 2
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

635 CASTLESTONE CT
ONEIDA WI
54155-9385
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3640
  • Fax: 920-433-3716
Mailing address:
  • Phone: 920-676-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15486-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: