Healthcare Provider Details

I. General information

NPI: 1508110776
Provider Name (Legal Business Name): BETH A LANE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH ANN JACOBS ANP

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 HWY 70
MINOCQUA WI
54548-9067
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1000
  • Fax:
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2012038004
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-013053
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11241
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: