Healthcare Provider Details

I. General information

NPI: 1295842805
Provider Name (Legal Business Name): JULIE M HENRY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE MARIE RONK

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54935
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7000
  • Fax: 920-907-7012
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2979-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: