Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 6672-33 | WI |
NPI | 1033562699 |
---|---|
Provider Name | Mr. Caleb Robert Bernhardt |
First Address | Allouez, WI 54301-1316 |
Second Address | Apo, AA 79920-5001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2016 |
Last Update Date | 19/07/2016 |