Healthcare Provider Details

I. General information

NPI: 1932082344
Provider Name (Legal Business Name): FUNCTIONAL NUTRITION & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MAIN ST
SAINT CLOUD WI
53079-1476
US

IV. Provider business mailing address

N2999 HONEYMOON HILL RD
NEW HOLSTEIN WI
53061-9727
US

V. Phone/Fax

Practice location:
  • Phone: 920-286-2800
  • Fax:
Mailing address:
  • Phone: 920-286-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANN PAUL
Title or Position: OWNER
Credential: PA
Phone: 920-286-2800