Healthcare Provider Details

I. General information

NPI: 1831698430
Provider Name (Legal Business Name): LAKESIDE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SHERIDAN RD STE 104
KENOSHA WI
53140-1921
US

IV. Provider business mailing address

2113 TALLGRASS CIR
WAUKESHA WI
53188-2606
US

V. Phone/Fax

Practice location:
  • Phone: 262-225-1014
  • Fax:
Mailing address:
  • Phone: 262-225-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011006054
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number6190-33
License Number StateWI

VIII. Authorized Official

Name: DR. ANTHONY HALE
Title or Position: OWNER
Credential: DNP, FNP-BC
Phone: 262-225-1014