Provider Demographics
NPI:1285135467
Name:DOUD, MILLICENT JOANNA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:JOANNA
Last Name:DOUD
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W309S10910 COUNTY HWY I
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149
Mailing Address - Country:US
Mailing Address - Phone:262-422-8038
Mailing Address - Fax:
Practice Address - Street 1:LAKE GENEVA 146 E GENEVA SQUARE
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53157
Practice Address - Country:US
Practice Address - Phone:262-422-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8165363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100075486Medicaid