Healthcare Provider Details

I. General information

NPI: 1518933969
Provider Name (Legal Business Name): GWEN M KANDULA AU.D, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: GWEN M VAN ROOY AU.D, MBA

II. Dates (important events)

Enumeration Date: 02/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAYFAIR RD STE 120
MILWAUKEE WI
53226-3255
US

IV. Provider business mailing address

14150 CHESTERWOOD DR
BROOKFIELD WI
53005-2381
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-6780
  • Fax: 414-238-2424
Mailing address:
  • Phone: 414-771-6780
  • Fax: 414-238-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number434 156
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: