Healthcare Provider Details

I. General information

NPI: 1134505357
Provider Name (Legal Business Name): EMILY ROSE KOTLOSKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 HIGGINS AVE
NEENAH WI
54956-3343
US

IV. Provider business mailing address

608 HIGGINS AVE
NEENAH WI
54956-3343
US

V. Phone/Fax

Practice location:
  • Phone: 715-551-0034
  • Fax:
Mailing address:
  • Phone: 715-551-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number180490-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: