Provider Demographics
NPI:1992812416
Name:IVANTIC, KAREN ANN (A) (NP)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:ANN (A)
Last Name:IVANTIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:ANN
Other - Last Name:IVANTIC-DOUCETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1575 N RIVER CENTER DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-283-8473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74022-030363L00000X
WI817-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner