Healthcare Provider Details

I. General information

NPI: 1407121775
Provider Name (Legal Business Name): ANNA MARIE WOLLBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

IV. Provider business mailing address

N1826 TOWER RD
MELROSE WI
54642-8224
US

V. Phone/Fax

Practice location:
  • Phone: 608-989-2745
  • Fax: 608-785-5331
Mailing address:
  • Phone: 715-896-4812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1854127
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: