Provider Demographics
NPI:1003573841
Name:DERKSEN, ELISSA M (LPN)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:M
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 HARTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2409
Mailing Address - Country:US
Mailing Address - Phone:920-309-2018
Mailing Address - Fax:
Practice Address - Street 1:2422 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6105
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30994431164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse