Healthcare Provider Details

I. General information

NPI: 1427191881
Provider Name (Legal Business Name): ALYCE ANASTASIA HOFMANN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 REENA AVE SUITE B
FORT ATKINSON WI
53538-3145
US

IV. Provider business mailing address

740 REENA AVE SUITE B
FORT ATKINSON WI
53538-3145
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-8468
  • Fax:
Mailing address:
  • Phone: 920-563-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009524
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3138-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: