Basic Information
| Provider Information | |||||||||
| NPI: | 1801088695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEGARE | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BIRKHOLZ-LUEDEMAN | ||||||||
| OtherFirstName: | DEBRA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4131 W LOOMIS RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1928 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204369002 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 08/15/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | WI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.