Healthcare Provider Details

I. General information

NPI: 1043144959
Provider Name (Legal Business Name): DAVIAN WILLEMS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1476 KENWOOD DR STE 101
MENASHA WI
54952-1134
US

IV. Provider business mailing address

975 LEE AVE
DE PERE WI
54115-1130
US

V. Phone/Fax

Practice location:
  • Phone: 920-264-5564
  • Fax:
Mailing address:
  • Phone: 920-264-5564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberNONE
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: