Healthcare Provider Details

I. General information

NPI: 1205943404
Provider Name (Legal Business Name): NANCY LYNN WHITEHEAD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 PLEASANT VALLEY RD
WEST BEND WI
53095-9767
US

IV. Provider business mailing address

743 S 7TH AVE
WEST BEND WI
53095-3944
US

V. Phone/Fax

Practice location:
  • Phone: 262-675-6533
  • Fax: 262-675-2827
Mailing address:
  • Phone: 262-334-7921
  • Fax: 262-334-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1914-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: