Healthcare Provider Details

I. General information

NPI: 1073577607
Provider Name (Legal Business Name): LEANN M DERUNGS APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 E RACINE ST
JANESVILLE WI
53546-2343
US

IV. Provider business mailing address

3200 E RACINE ST
JANESVILLE WI
53546-2343
US

V. Phone/Fax

Practice location:
  • Phone: 608-371-8000
  • Fax: 608-371-8943
Mailing address:
  • Phone: 608-371-8000
  • Fax: 608-371-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2052
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: