Provider Demographics
NPI:1679773915
Name:PRAVECHEK, JENNIFER LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:PRAVECHEK
Suffix:
Gender:F
Credentials:NP-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:
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI285485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36047500Medicaid
WI078450039Medicare Oscar/Certification
WIP00732992Medicare Oscar/Certification
WI073550086Medicare Oscar/Certification