Healthcare Provider Details

I. General information

NPI: 1720713753
Provider Name (Legal Business Name): SHAUNA LEE KOFOED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 N 18TH ST
MANITOWOC WI
54220-3131
US

IV. Provider business mailing address

860 N 18TH ST
MANITOWOC WI
54220-3131
US

V. Phone/Fax

Practice location:
  • Phone: 414-708-6119
  • Fax:
Mailing address:
  • Phone: 414-708-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number148381
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: