Provider Demographics
NPI:1285083139
Name:KNISBECK, DEBRA (NURSE PRACTITONER)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:KNISBECK
Suffix:
Gender:F
Credentials:NURSE PRACTITONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2743
Mailing Address - Country:US
Mailing Address - Phone:262-224-4649
Mailing Address - Fax:
Practice Address - Street 1:626 FOXTAIL DR
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2743
Practice Address - Country:US
Practice Address - Phone:262-224-4649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6991-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6991-33OtherSTATE OF WISCONSIN