Healthcare Provider Details

I. General information

NPI: 1508691569
Provider Name (Legal Business Name): TAYLOR FENSKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 S 108TH ST
GREENFIELD WI
53228-2504
US

IV. Provider business mailing address

11221 SYNERGY DR APT 489
WAUWATOSA WI
53222-1310
US

V. Phone/Fax

Practice location:
  • Phone: 414-427-5310
  • Fax:
Mailing address:
  • Phone: 414-539-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1587833
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number24913430
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: