Provider Demographics
NPI:1407961402
Name:GRANKE, LESLEE A (APNP)
Entity Type:Individual
Prefix:MS
First Name:LESLEE
Middle Name:A
Last Name:GRANKE
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 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-598-4881
Practice Address - Street 1:15397 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:715-276-1428
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75395163W00000X
WI133-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43836400Medicaid