Basic Information
Provider Information | |||||||||
NPI: | 1891749156 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAINES | ||||||||
FirstName: | TAMAHRA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LANGHOFF | ||||||||
OtherFirstName: | TAMARA | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 420 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209268340 | ||||||||
FaxNumber: | 9209268370 | ||||||||
Practice Location | |||||||||
Address1: | 371 1ST ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209073967 | ||||||||
FaxNumber: | 4142663735 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 05/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1592 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0200X | 1592 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 39945600 | 05 | WI |   | MEDICAID |