Healthcare Provider Details

I. General information

NPI: 1184566739
Provider Name (Legal Business Name): NANETTE MARIE PAMONICUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

IV. Provider business mailing address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3835
  • Fax:
Mailing address:
  • Phone: 715-799-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20597-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: