Basic Information
Provider Information | |||||||||
NPI: | 1598055816 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FEUSTEL | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANBORN | ||||||||
OtherFirstName: | PAMELA | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 53585 NOKOMIS ROAD | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 548064272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156827133 | ||||||||
FaxNumber: | 7156857857 | ||||||||
Practice Location | |||||||||
Address1: | 53585 NOKOMIS ROAD | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 548064272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156827133 | ||||||||
FaxNumber: | 7156857857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2011 | ||||||||
LastUpdateDate: | 11/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 154788-30 | WI | N |   | Other Service Providers | Community Health Worker |   | 163W00000X | 154788-30 | WI | Y |   | Nursing Service Providers | Registered Nurse |   | 163WC1500X | 154788-30 | WI | N |   | Nursing Service Providers | Registered Nurse | Community Health | 163WH0200X | 154788-30 | WI | N |   | Nursing Service Providers | Registered Nurse | Home Health |
No ID Information.