Provider Demographics
NPI:1750125514
Name:DETTLAFF, SARA (APNP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DETTLAFF
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 CASTLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:WI
Mailing Address - Zip Code:54155-9385
Mailing Address - Country:US
Mailing Address - Phone:920-676-5196
Mailing Address - Fax:
Practice Address - Street 1:744 S WEBSTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-433-3716
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI15486-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily