Healthcare Provider Details

I. General information

NPI: 1487374625
Provider Name (Legal Business Name): EMILY WOLTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST
MADISON WI
53715-1507
US

IV. Provider business mailing address

1309 WINSLOW LN
MADISON WI
53711-3737
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13159-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178958-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: