Provider Demographics
NPI:1417630211
Name:HARTER, AVERY MADISON (NP)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:MADISON
Last Name:HARTER
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 1:5471 W WATERFORD LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8510
Mailing Address - Country:US
Mailing Address - Phone:920-731-7445
Mailing Address - Fax:
Practice Address - Street 1:5471 W WATERFORD LN
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8510
Practice Address - Country:US
Practice Address - Phone:920-731-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14669-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner