Healthcare Provider Details

I. General information

NPI: 1730882432
Provider Name (Legal Business Name): GRACE ELIZABETH KOONTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SCIENCE DR
MADISON WI
53711-1074
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-915-0570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number82174
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: