Provider Demographics
NPI:1114438348
Name:MUDGETT, TANYA (APNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MUDGETT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18601 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-8605
Mailing Address - Country:US
Mailing Address - Phone:715-538-1712
Mailing Address - Fax:
Practice Address - Street 1:18606 ERVIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-8613
Practice Address - Country:US
Practice Address - Phone:715-538-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily