Provider Demographics
NPI:1952409732
Name:DERGE, ANN T (BSN, RN-C, APNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:T
Last Name:DERGE
Suffix:
Gender:F
Credentials:BSN, RN-C, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 PARK PL
Mailing Address - Street 2:STE 200
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1974
Mailing Address - Country:US
Mailing Address - Phone:920-498-8650
Mailing Address - Fax:920-498-0945
Practice Address - Street 1:1537 PARK PL
Practice Address - Street 2:STE 200
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1974
Practice Address - Country:US
Practice Address - Phone:920-498-8650
Practice Address - Fax:920-498-0945
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1014-033363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000207365OtherMEDICARE
WISTATE LICENSEOther1014-033
WISTATE LICENSEOther82393-030
MD0360610OtherDEA LICENSE
MD0360610OtherDEA LICENSE