Healthcare Provider Details

I. General information

NPI: 1811958028
Provider Name (Legal Business Name): LUCY R CANADAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E HIGHLAND DR
OCONTO FALLS WI
54154-1002
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-3092
  • Fax: 920-846-8313
Mailing address:
  • Phone: 920-445-7226
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47569-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: