Healthcare Provider Details

I. General information

NPI: 1760946628
Provider Name (Legal Business Name): AMIE JABANG APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 EXECUTIVE DR
OCONOMOWOC WI
53066-4830
US

IV. Provider business mailing address

36100 GENESEE LAKE RD
OCONOMOWOC WI
53066-9201
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-5515
  • Fax:
Mailing address:
  • Phone: 262-569-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18460.33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: