Healthcare Provider Details

I. General information

NPI: 1336366111
Provider Name (Legal Business Name): MARY A ZINDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 E 1ST ST
FOND DU LAC WI
54935-4505
US

IV. Provider business mailing address

459 E 1ST ST
FOND DU LAC WI
54935-4505
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-3568
  • Fax:
Mailing address:
  • Phone: 920-929-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number951
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: