Provider Demographics
NPI:1952722324
Name:PRUSAK, COURTNEY (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 NAUTICAL DR
Mailing Address - Street 2:APT 3
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3532
Practice Address - Country:US
Practice Address - Phone:920-746-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5633-33363LF0000X
WI5633363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily