Provider Demographics
NPI:1194122861
Name:PETHAN, LAURA B (APNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:B
Last Name:PETHAN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:B
Other - Last Name:SCHARENBROCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3008
Practice Address - Fax:608-825-3786
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7462-33363LP0200X
IL209012238363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400363391Medicare PIN