=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275342503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RUNYON APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 05/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 PINE RIDGE BLVD
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-4187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-283-2881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2705
-----------------------------------------------------
City | EAGLE RIVER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54521-2705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-317-0062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 16323-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 16323-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------