Healthcare Provider Details

I. General information

NPI: 1447814108
Provider Name (Legal Business Name): AMY L O'CONNELL CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-5984
  • Fax: 920-831-5093
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2053
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: