Provider Demographics
NPI:1346086626
Name:ETIENNE, JACQUELYN MARIE (APNP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MARIE
Other - Last Name:DEQUAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:725 S WEBSTER AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-430-7100
Practice Address - Fax:920-430-7114
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15553-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily