MEDICARE: LANETTE LYNN DAVIS PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	14426-33	WI

General Provider Information

NPI Number	:	1336927243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANETTE LYNN DAVIS PMHNP

Provider Business Mailing Address
First Line	:	1516 S GREEN BAY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-5789
Country	:	US
Telephone Number	:	262-900-1111
Fax Number	:	262-748-1605

Provider Business Practice Location Address
First Line	:	1516 S GREEN BAY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-5789
Country	:	US
Telephone Number	:	262-900-1111
Fax Number	:	262-748-1605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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