Healthcare Provider Details

I. General information

NPI: 1053276162
Provider Name (Legal Business Name): ALICE WAECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N64W25037 PROSPECT CIR
SUSSEX WI
53089-2680
US

IV. Provider business mailing address

N57W26347 MOUNTAIN MEADOWS DR
SUSSEX WI
53089-4037
US

V. Phone/Fax

Practice location:
  • Phone: 262-532-8680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17648-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: