Provider Demographics
NPI:1154438760
Name:EDEBOHLS, LYNNE M (APNP)
Entity type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:M
Last Name:EDEBOHLS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1304
Mailing Address - Country:US
Mailing Address - Phone:920-648-4518
Mailing Address - Fax:920-648-1623
Practice Address - Street 1:1025 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1304
Practice Address - Country:US
Practice Address - Phone:920-648-4518
Practice Address - Fax:920-648-1623
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1323-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43891700Medicaid
000854100OtherMEDICARE A
000854100OtherMEDICARE A
521822Medicare ID - Type UnspecifiedPART B
WIS87711Medicare UPIN