Healthcare Provider Details

I. General information

NPI: 1295463743
Provider Name (Legal Business Name): EAMEN GEBOY APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13133 N PORT WASHINGTON RD
MEQUON WI
53097-2419
US

IV. Provider business mailing address

788 N JEFFERSON STREET SUITE 300/ATTN. KAAREN BUTZEN
MILWAUKEE WI
53202-3710
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-5000
  • Fax:
Mailing address:
  • Phone: 414-272-8950
  • Fax: 414-326-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13070
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13070
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13070-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: