Provider Demographics
NPI:1215236278
Name:DETTLAFF, ANN ELIZABETH (APNP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:DETTLAFF
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:ELIZABETH
Other - Last Name:PRIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:720 W. ASSOCIATION DR.
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914
Mailing Address - Country:US
Mailing Address - Phone:920-731-4354
Mailing Address - Fax:920-731-5021
Practice Address - Street 1:720 W. ASSOCIATION DR.
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-731-4354
Practice Address - Fax:920-731-5021
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4360-33363L00000X
WI4360-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014463Medicaid
WI1215236278Medicaid