Provider Demographics
NPI:1114240199
Name:VAN LANNEN, TAMARA J (NP)
Entity Type:Individual
Prefix:MISS
First Name:TAMARA
Middle Name:J
Last Name:VAN LANNEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:414-246-6400
Mailing Address - Fax:
Practice Address - Street 1:9000 W SURA LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3477
Practice Address - Country:US
Practice Address - Phone:414-246-6400
Practice Address - Fax:414-246-6405
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163165-30163W00000X
WI5880-33363LF0000X
WI5880363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100040042Medicaid