Basic Information
| Provider Information | |||||||||
| NPI: | 1962410530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASENCIO | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
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| Practice Location | |||||||||
| Address1: | 146 E GENEVA SQ | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622495000 | ||||||||
| FaxNumber: | 2622497142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1853-033 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 134897-030 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43938100 | 05 | WI | MEDICAID |