Healthcare Provider Details

I. General information

NPI: 1629989736
Provider Name (Legal Business Name): DEVON ELIZABETH DEYOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W197N16948 STONEWALL DR
JACKSON WI
53037-8617
US

IV. Provider business mailing address

W197N16948 STONEWALL DR
JACKSON WI
53037-8617
US

V. Phone/Fax

Practice location:
  • Phone: 920-348-3124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19134-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: