Provider Demographics
NPI:1336927243
Name:DAVIS, LANETTE LYNN (PMHNP)
Entity Type:Individual
Prefix:
First Name:LANETTE
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:LANETTE
Other - Middle Name:LYNN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1516 S GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5789
Mailing Address - Country:US
Mailing Address - Phone:262-900-1111
Mailing Address - Fax:262-748-1605
Practice Address - Street 1:1516 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-5789
Practice Address - Country:US
Practice Address - Phone:262-900-1111
Practice Address - Fax:262-748-1605
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14426-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health