Provider Demographics
NPI:1750841482
Name:GROSS, JOHANNA LOUISE
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LOUISE
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4963 N 125TH ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:WI
Mailing Address - Zip Code:53007-1532
Mailing Address - Country:US
Mailing Address - Phone:262-370-7460
Mailing Address - Fax:
Practice Address - Street 1:7901 S 6TH ST
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-2010
Practice Address - Country:US
Practice Address - Phone:414-346-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9156-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9156-33Medicaid