Healthcare Provider Details

I. General information

NPI: 1467593079
Provider Name (Legal Business Name): DEBORAH A HERCZOG M.S.N., A.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 FRONT ST S
LA CROSSE WI
54601-4023
US

IV. Provider business mailing address

N2994 PEBBLE VALLEY RD
STODDARD WI
54658-9018
US

V. Phone/Fax

Practice location:
  • Phone: 608-783-7560
  • Fax:
Mailing address:
  • Phone: 608-787-0172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number531773
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: