Healthcare Provider Details

I. General information

NPI: 1669423059
Provider Name (Legal Business Name): LORETTA L BUSH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC ENDOCRINOLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC ENDOCRINOLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-7650
  • Fax: 414-266-6749
Mailing address:
  • Phone: 414-266-7650
  • Fax: 414-266-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2591
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: