Healthcare Provider Details

I. General information

NPI: 1497166870
Provider Name (Legal Business Name): RACHELLE B MANKE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHELLE EWALD

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 W LOOMIS RD SUITE 300
GREENFIELD WI
53221-2057
US

IV. Provider business mailing address

4131 W LOOMIS RD SUITE 300
GREENFIELD WI
53221-2057
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7246
  • Fax: 414-325-3770
Mailing address:
  • Phone: 414-325-7246
  • Fax: 414-325-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5816
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166062-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: