Healthcare Provider Details

I. General information

NPI: 1124337043
Provider Name (Legal Business Name): JILL M GREVENOW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL M WALLANDER

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N 92ND ST PEDIATRIC SPECIAL NEEDS
MILWAUKEE WI
53226-4875
US

IV. Provider business mailing address

999 N 92ND ST PEDIATRIC SPECIAL NEEDS
MILWAUKEE WI
53226-4875
US

V. Phone/Fax

Practice location:
  • Phone: 414-337-7158
  • Fax: 414-266-2926
Mailing address:
  • Phone: 414-337-7158
  • Fax: 414-266-2926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number147817
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: