MEDICARE: VIVIAN L DEHAHN APNP

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	163W00000X	Registered Nurse	88058-030	WI
2	363L00000X	Nurse Practitioner	1451-033	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538154539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN L DEHAHN APNP

Provider Business Mailing Address
First Line	:	33300 CAYUGA WAY
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-9633
Country	:	US
Telephone Number	:	262-210-0563
Fax Number	:

Provider Business Practice Location Address
First Line	:	33300 CAYUGA WAY
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-9633
Country	:	US
Telephone Number	:	262-210-0563
Fax Number	:

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	11/30/2021

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