Healthcare Provider Details

I. General information

NPI: 1609410364
Provider Name (Legal Business Name): LATEISHA PRESCOTT APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34700 VALLEY RD
OCONOMOWOC WI
53066-4599
US

IV. Provider business mailing address

4600 W SCHROEDER DR
BROWN DEER WI
53223-6458
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-4411
  • Fax:
Mailing address:
  • Phone: 414-865-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number176126-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10005-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: