Healthcare Provider Details

I. General information

NPI: 1982252631
Provider Name (Legal Business Name): LORRIE ANN FORMELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N RICHMOND ST
APPLETON WI
54911-4659
US

IV. Provider business mailing address

N7590 LOWER CLIFF RD
SHERWOOD WI
54169-9704
US

V. Phone/Fax

Practice location:
  • Phone: 920-750-1845
  • Fax:
Mailing address:
  • Phone: 920-750-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: