Healthcare Provider Details

I. General information

NPI: 1760306146
Provider Name (Legal Business Name): ELIZABETH VANEGEREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH VAN ROSSUM

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-5696
  • Fax: 920-431-5677
Mailing address:
  • Phone: 920-431-5696
  • Fax: 920-431-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23466-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: