Healthcare Provider Details

I. General information

NPI: 1194338160
Provider Name (Legal Business Name): QUEENETH N EGWU DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805B SPRING ST STE 140
MOUNT PLEASANT WI
53405-1642
US

IV. Provider business mailing address

3030 NICKLAUS LN
WADSWORTH IL
60083-8944
US

V. Phone/Fax

Practice location:
  • Phone: 262-506-1695
  • Fax: 262-440-2853
Mailing address:
  • Phone: 847-693-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number116433-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021726
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: