Healthcare Provider Details

I. General information

NPI: 1164089991
Provider Name (Legal Business Name): HEIDI CATHERINE PUHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 S 22ND RD
SOUTH RANGE WI
54874-8849
US

IV. Provider business mailing address

3484 S 22ND RD
SOUTH RANGE WI
54874-8849
US

V. Phone/Fax

Practice location:
  • Phone: 218-428-0377
  • Fax:
Mailing address:
  • Phone: 218-428-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: