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General NPI Number Information
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NPI Number | 1831698430
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Entity Type | Organization
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Legal Business Name | LAKESIDE FAMILY PRACTICE
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Dates
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Enumeration Date | 02/08/2018
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Last Update Date | 02/08/2018
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Provider Practice Location Address
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Address Line | 3200 SHERIDAN RD STE 104
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City | KENOSHA
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State | WI
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Zip | 53140-1921
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Country | US
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Telephone | 262-225-1014
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Fax |
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Provider Business Mailing Address
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Address Line | 2113 TALLGRASS CIR
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City | WAUKESHA
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State | WI
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Zip | 53188-2606
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Country | US
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Telephone | 262-225-1014
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANTHONY HALE
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Credential | DNP, FNP-BC
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Telephone | 262-225-1014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 6190-33
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2011006054
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License Number State | WI
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