Basic Information
Provider Information | |||||||||
NPI: | 1568114858 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THIMM | ||||||||
FirstName: | JANELLE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CAA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LANG-PIETTE | ||||||||
OtherFirstName: | JANELLE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CAA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148058700 | ||||||||
FaxNumber: | 4142591522 | ||||||||
Practice Location | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148058700 | ||||||||
FaxNumber: | 4142591522 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2022 | ||||||||
LastUpdateDate: | 09/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 206-17 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1568114858 | 05 | WI |   | MEDICAID | 32698078 | 01 |   | NATIONAL COMMISSION CERTIFICATION ANESTHESIA ASSISTANTS | OTHER |