Provider Demographics
NPI:1902153844
Name:PROM, JENNIFER KRISTIN (APNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KRISTIN
Last Name:PROM
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 1:9025 OAKRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9388
Mailing Address - Country:US
Mailing Address - Phone:262-375-6858
Mailing Address - Fax:
Practice Address - Street 1:9025 OAKRIDGE LN
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-9388
Practice Address - Country:US
Practice Address - Phone:262-375-6858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4891-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily