Basic Information
| Provider Information | |||||||||
| NPI: | 1407961402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANKE | ||||||||
| FirstName: | LESLEE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7155984881 | ||||||||
| Practice Location | |||||||||
| Address1: | 15397 STATE HIGHWAY 32 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152766321 | ||||||||
| FaxNumber: | 7152761428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 10/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 75395 | WI | N | Nursing Service Providers | Registered Nurse | 363L00000X | 133-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43836400 | 05 | WI | MEDICAID |