Provider Demographics
NPI:1922848530
Name:CONWAY, JACQUELINE LEIGH (APNP-FNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEIGH
Last Name:CONWAY
Suffix:
Gender:F
Credentials:APNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3113
Mailing Address - Country:US
Mailing Address - Phone:608-897-6081
Mailing Address - Fax:
Practice Address - Street 1:1904 1ST CENTER AVE
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-1900
Practice Address - Country:US
Practice Address - Phone:608-897-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15266363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care