Healthcare Provider Details

I. General information

NPI: 1346327392
Provider Name (Legal Business Name): TINA MARIE DEGROOT APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RIDGE ST
STOUGHTON WI
53589-1864
US

IV. Provider business mailing address

900 RIDGE ST
STOUGHTON WI
53589-1864
US

V. Phone/Fax

Practice location:
  • Phone: 608-873-6611
  • Fax:
Mailing address:
  • Phone: 608-873-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number3554-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: