Healthcare Provider Details

I. General information

NPI: 1629664891
Provider Name (Legal Business Name): MEGAN SUE PUTHOFF FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 S 20TH ST
MILWAUKEE WI
53215-3732
US

IV. Provider business mailing address

PO BOX 778789
CHICAGO IL
60677-8789
US

V. Phone/Fax

Practice location:
  • Phone: 414-299-0656
  • Fax:
Mailing address:
  • Phone: 414-672-1353
  • Fax: 414-672-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10621-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10621
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: