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NPI Code Detail

MEDICARE: ANGELA YVONNE PUCHALLA LAT, ATC

MEDICARE: ANGELA YVONNE PUCHALLA LAT, ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer549-039WI

General Provider Information

NPI Number : 1114917580
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANGELA YVONNE PUCHALLA LAT, ATC
Provider Business Mailing Address
First Line : 1445 CARROLL AVE
Second Line :
City : GREEN BAY
State : WI
Zip : 54304-3412
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1630 COMMANCHE AVE
Second Line :
City : GREEN BAY
State : WI
Zip : 54313-5753
Country : US
Telephone Number : 920-655-3005
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2005
Last Update Date : 07/08/2007

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