Healthcare Provider Details

I. General information

NPI: 1194122861
Provider Name (Legal Business Name): LAURA B PETHAN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA B SCHARENBROCH APNP

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-3008
  • Fax: 608-825-3786
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number7462-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: