Healthcare Provider Details

I. General information

NPI: 1699697847
Provider Name (Legal Business Name): LEGACY OF FOUR SISTERA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N9351 S LAKE PARK RD UNIT 132
APPLETON WI
54915-9488
US

IV. Provider business mailing address

N9351 S LAKE PARK RD UNIT 132
APPLETON WI
54915-9488
US

V. Phone/Fax

Practice location:
  • Phone: 920-515-1534
  • Fax:
Mailing address:
  • Phone: 920-515-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: DYNA INGABIRE
Title or Position: DIRECTOR
Credential:
Phone: 920-515-1534