1447316997 NPI number — MRS. JILLIANN NELESSEN PRUETTING PT

Table of content: MRS. JILLIANN NELESSEN PRUETTING PT (NPI 1447316997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447316997 NPI number — MRS. JILLIANN NELESSEN PRUETTING PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUETTING
Provider First Name:
JILLIANN
Provider Middle Name:
NELESSEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NELESSEN
Provider Other First Name:
JILLIANN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447316997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2414 SPRINGDALE RD
Provider Second Line Business Mailing Address:
# 103
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53186-2779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-427-1354
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 E NEWPORT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-298-6700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  10556-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)