Basic Information
Provider Information | |||||||||
NPI: | 1821482795 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOCHESATO | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RISNER | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22040 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543052040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457222 | ||||||||
FaxNumber: | 9204457289 | ||||||||
Practice Location | |||||||||
Address1: | 2820 ROOSEVELT RD | ||||||||
Address2: |   | ||||||||
City: | MARINETTE | ||||||||
State: | WI | ||||||||
PostalCode: | 541433834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204336073 | ||||||||
FaxNumber: | 7157355388 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2015 | ||||||||
LastUpdateDate: | 03/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9202-33 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 9202-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 2019074038 | 01 |   | AMERICAN NURSES CREDENTIALING CENTER | OTHER | F0215315 | 01 |   | AMERICAN ACADEMY OF NURSE PRACTITIONERS | OTHER |