Healthcare Provider Details

I. General information

NPI: 1316346505
Provider Name (Legal Business Name): MRS. CONNIE ANN LENTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 HALL AVE
MARINETTE WI
54143-1721
US

IV. Provider business mailing address

N2980 N 9TH RD
COLEMAN WI
54112-9446
US

V. Phone/Fax

Practice location:
  • Phone: 715-735-5078
  • Fax:
Mailing address:
  • Phone: 715-923-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: