Healthcare Provider Details

I. General information

NPI: 1235552860
Provider Name (Legal Business Name): MARISA RENEE OPSAHL R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N896 KRANZ RD
COLUMBUS WI
53925-9726
US

IV. Provider business mailing address

N896 KRANZ RD
COLUMBUS WI
53925-9726
US

V. Phone/Fax

Practice location:
  • Phone: 608-669-0182
  • Fax:
Mailing address:
  • Phone: 608-669-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number199198-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: