Healthcare Provider Details

I. General information

NPI: 1114992492
Provider Name (Legal Business Name): AGNESIAN HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

430 E DIVISION ST PO BOX 385
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-4666
  • Fax:
Mailing address:
  • Phone: 920-926-4472
  • Fax: 920-926-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AMY GRINNELL
Title or Position: VP-FINANCE, CFO
Credential:
Phone: 608-260-3586