=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790794329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERO-PSYCH NURSING, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19822 W GOOD HOPE RD
-----------------------------------------------------
City | LANNON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53046-9775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-251-3808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19822 W GOOD HOPE RD
-----------------------------------------------------
City | LANNON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53046-9775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-251-3808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. BEVERLY SIGL FELTEN
-----------------------------------------------------
Credential | PHD, RN, APNP
-----------------------------------------------------
Telephone | 262-251-3808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 4-033
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------