Provider Demographics
NPI:1609252139
Name:ENGEBOSE, ELYSE MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:MARIE
Last Name:ENGEBOSE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:140B SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1095
Practice Address - Country:US
Practice Address - Phone:920-845-1370
Practice Address - Fax:920-845-1379
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6533-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07151158OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS
WIK400256981Medicare Oscar/Certification