Provider Demographics
NPI:1235436841
Name:SCHULTZ, PENNY JO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JO
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E VETERANS ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-3105
Mailing Address - Country:US
Mailing Address - Phone:608-372-3791
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4348-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI115450-030OtherRESISTERED NURSE
WI4348-33OtherADVANCED PRACTICE NURSE PRESCRIBER LICENSE