Healthcare Provider Details

I. General information

NPI: 1235848334
Provider Name (Legal Business Name): MARY VANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 S TAYLOR DR
SHEBOYGAN WI
53081-8495
US

IV. Provider business mailing address

1257 KAUFMANN AVE
SHEBOYGAN WI
53081-7618
US

V. Phone/Fax

Practice location:
  • Phone: 920-459-8601
  • Fax:
Mailing address:
  • Phone: 715-302-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21468-40
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number21468-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: