Provider Demographics
NPI:1871967505
Name:CHAMPEAU, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:CHAMPEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2628
Mailing Address - Country:US
Mailing Address - Phone:920-631-7031
Mailing Address - Fax:920-631-7031
Practice Address - Street 1:1132 MADISON ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2628
Practice Address - Country:US
Practice Address - Phone:920-631-7031
Practice Address - Fax:920-631-7031
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIM087406374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide