Healthcare Provider Details

I. General information

NPI: 1982623534
Provider Name (Legal Business Name): JOHN H BRADLEY DEPTARTMENT OF VETERANS AFFAIRS OUTPATIENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRI-PARKWAY
APPLETON WI
54914
US

IV. Provider business mailing address

7187 ANGELL RD
OSHKOSH WI
54904-9544
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-0070
  • Fax:
Mailing address:
  • Phone: 920-836-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1456029
License Number StateWI

VIII. Authorized Official

Name: DEBORAH LYNN WOELFEL
Title or Position: REGISTERED DIETITIAN
Credential: RD, CDE
Phone: 920-831-0070