Provider Demographics
NPI:1053839571
Name:HARRIS, ANNETTE S (NP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:S
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:S
Other - Last Name:GOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:12203 CORPORATE PKWY
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3388
Mailing Address - Country:US
Mailing Address - Phone:262-387-8239
Mailing Address - Fax:
Practice Address - Street 1:12203 CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3388
Practice Address - Country:US
Practice Address - Phone:262-387-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner