Provider Demographics
NPI:1730474347
Name:LEDVINA, SALLY JO (APNP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:LEDVINA
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:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:E1430 KRINES RD
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-7731
Practice Address - Country:US
Practice Address - Phone:920-863-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4387-033363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health