Healthcare Provider Details

I. General information

NPI: 1851313852
Provider Name (Legal Business Name): ANGELICA M GRONKE RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/06/2013
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

1818 N MEADE ST
APPLETON WI
54911-3454
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-5359
  • Fax: 920-831-5093
Mailing address:
  • Phone: 920-738-5359
  • Fax: 920-831-5093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number155929
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: