1205451564 NPI number — GINGER RENEE BLAND APNP FNP-BC

Table of content: GINGER RENEE BLAND APNP FNP-BC (NPI 1205451564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205451564 NPI number — GINGER RENEE BLAND APNP FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAND
Provider First Name:
GINGER
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDER
Provider Other First Name:
GINGER
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205451564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N3354 NARCISSUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE GENEVA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53147-2945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-325-9973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11133 W. NATIONAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST ALLIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-327-2295
Provider Business Practice Location Address Fax Number:
414-328-4497
Provider Enumeration Date:
06/12/2020

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: 363L00000X , with the licence number:  10097-33 , 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)





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