Provider Demographics
NPI:1265754907
Name:BOCK, BARBARA BEAUDETTE (FNP)
Entity type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:BEAUDETTE
Last Name:BOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:ANN
Other - Last Name:BEAUDETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:N3995 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9618
Mailing Address - Country:US
Mailing Address - Phone:920-674-7105
Mailing Address - Fax:
Practice Address - Street 1:N3995 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9618
Practice Address - Country:US
Practice Address - Phone:920-674-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62427-30163W00000X
WI300-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse