1467599381 NPI number — MRS. COLETTE WYTTENBACH RD, CD, LD, CDE

Table of content: MRS. COLETTE WYTTENBACH RD, CD, LD, CDE (NPI 1467599381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467599381 NPI number — MRS. COLETTE WYTTENBACH RD, CD, LD, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYTTENBACH
Provider First Name:
COLETTE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CD, LD, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467599381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3005 13TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53566-2247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 22ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53566-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-324-2770
Provider Business Practice Location Address Fax Number:
608-324-2469
Provider Enumeration Date:
01/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43490400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".