Healthcare Provider Details

I. General information

NPI: 1710723374
Provider Name (Legal Business Name): JEREMY DONALD NELSEN APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

128 AUDUBON CT
GRAFTON WI
53024-2217
US

V. Phone/Fax

Practice location:
  • Phone: 414-585-1000
  • Fax:
Mailing address:
  • Phone: 262-689-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number15546-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: