Individual
JENNA K PROVANCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2414 KOHLER MEMORIAL DR, SHEBOYGAN, WI 53081-3129
(920) 457-4461
Mailing address
2414 W KOHLER MEMORIAL DR, SHEBOYGAN, WI 53081
(920) 457-4461
(920) 459-1483
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
4027-23
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1699295626
—
WI
01
—
K400398570
MEDICARE
WI
Enumeration date
06/21/2017
Last updated
12/01/2021
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