Healthcare Provider Details

I. General information

NPI: 1508234188
Provider Name (Legal Business Name): JESSICA ANGOVE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2015
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 N GRANDVIEW BLVD STE 202
WAUKESHA WI
53188-1660
US

IV. Provider business mailing address

N2779 COUNTY ROAD M
WATERTOWN WI
53098-3856
US

V. Phone/Fax

Practice location:
  • Phone: 262-513-0700
  • Fax:
Mailing address:
  • Phone: 920-342-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number6569-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6569-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: