Provider Demographics
NPI:1700525938
Name:MORTENSON, MEGHAN K
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:K
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6584
Mailing Address - Country:US
Mailing Address - Phone:920-265-2649
Mailing Address - Fax:
Practice Address - Street 1:1609 HUNTER RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8220
Practice Address - Country:US
Practice Address - Phone:262-524-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI176520163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI176520OtherWDSPS