Basic Information
| Provider Information | |||||||||
| NPI: | 1942926134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEISE | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | LAUREN BAUER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BAUER | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | N2246 COUNTY ROAD T | ||||||||
| Address2: | |||||||||
| City: | HORTONVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549449201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205383082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207314101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13204-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.