Provider Demographics
NPI:1275342503
Name:RUNYON, JESSICA (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RUNYON
Suffix:
Gender:
Credentials:APRN
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 2705
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-2705
Mailing Address - Country:US
Mailing Address - Phone:715-317-0062
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4187
Practice Address - Country:US
Practice Address - Phone:800-283-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16323-33163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse