Healthcare Provider Details

I. General information

NPI: 1134127319
Provider Name (Legal Business Name): THERESA KOHLRUSCH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

IV. Provider business mailing address

265 GRIFFIN STREET EAST
AMERY WI
54001
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax: 715-268-0311
Mailing address:
  • Phone: 715-268-8000
  • Fax: 715-268-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number858
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: