Healthcare Provider Details

I. General information

NPI: 1265713549
Provider Name (Legal Business Name): DEBORAH LYNN GLIME APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH LYNN JOHANEK

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 08/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-1000
US

IV. Provider business mailing address

2445 N 72ND ST
WAUWATOSA WI
53213-1203
US

V. Phone/Fax

Practice location:
  • Phone: 414-331-3765
  • Fax:
Mailing address:
  • Phone: 414-331-3765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4540-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: