Provider Demographics
NPI:1881024404
Name:FENNIMORE HEALING ARTS, LLC
Entity Type:Organization
Organization Name:FENNIMORE HEALING ARTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEASE
Authorized Official - Suffix:
Authorized Official - Credentials:APNP, PMHNP-BC
Authorized Official - Phone:608-572-3494
Mailing Address - Street 1:770 LINCOLN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FENNIMORE
Mailing Address - State:WI
Mailing Address - Zip Code:53809-1562
Mailing Address - Country:US
Mailing Address - Phone:608-572-3494
Mailing Address - Fax:608-822-3812
Practice Address - Street 1:770 LINCOLN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809-1562
Practice Address - Country:US
Practice Address - Phone:608-572-3494
Practice Address - Fax:608-822-3812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4062-33251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI849190006OtherMEDICARE PTAN
WI1215243852Medicaid