Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 2211 | WI |
NPI | 1003811902 |
---|---|
Provider Name | Pamela L Tennant |
First Address | La Crosse, WI 54601-5429 |
Second Address | La Crosse, WI 54601-5429 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2005 |
Last Update Date | 24/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38253900 | (05) | WI |
Q17552 | (02) | WI |