MEDICARE: INTEGRATIVE MEDICAL SOLUTIONS OF LAKE MILLS LLC

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1497419956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE MEDICAL SOLUTIONS OF LAKE MILLS LLC

Provider Business Mailing Address
First Line	:	125 E PINE ST STE C
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-5271
Fax Number	:	920-648-4365

Provider Business Practice Location Address
First Line	:	125 E PINE ST STE C
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-5271
Fax Number	:	920-648-4365

Authorized Official
Title or Position	:	ADV PRACTICE NURSE PRACTITIONER
Name	:	PROF. NICOLE LEE BERG-JOHNSON
Credential	:	RN, APNP
Telephone Number	:	262-510-7412

Provider Enumeration Date	:	10/29/2021
Last Update Date	:	10/29/2021

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