Healthcare Provider Details

I. General information

NPI: 1225165517
Provider Name (Legal Business Name): LINDA DEKEYSER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 CEDAR CIR
STURGEON BAY WI
54235-8372
US

IV. Provider business mailing address

9729 SCHOOL RD
BRUSSELS WI
54204-9502
US

V. Phone/Fax

Practice location:
  • Phone: 920-825-1255
  • Fax:
Mailing address:
  • Phone: 920-825-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number26095-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: