Provider Demographics
NPI:1174958193
Name:DESSART, ERICA L (NP)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:DESSART
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 1:5300 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-793-7420
Mailing Address - Fax:920-793-7430
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:920-793-7420
Practice Address - Fax:920-793-7430
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5420-33363L00000X
WI5420363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100065260Medicaid
WI100065388Medicaid