Healthcare Provider Details

I. General information

NPI: 1982810602
Provider Name (Legal Business Name): VIRGINIA ROSE PRIEST LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N3631 SLATTS RD
CASCADE WI
53011-1105
US

IV. Provider business mailing address

N3631 SLATTS RD
CASCADE WI
53011-1105
US

V. Phone/Fax

Practice location:
  • Phone: 920-528-7072
  • Fax:
Mailing address:
  • Phone: 920-528-7072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number16-049
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: