Basic Information
| Provider Information | |||||||||
| NPI: | 1770938771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLWEG | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEALEY | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2825 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087427161 | ||||||||
| FaxNumber: | 6087453990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087427161 | ||||||||
| FaxNumber: | 6087453990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 6931-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P01729173 | 01 | WI | RAILROAD MEDICARE | OTHER | 1770938771 | 05 | WI | MEDICAID |