Healthcare Provider Details

I. General information

NPI: 1679631675
Provider Name (Legal Business Name): SALLY SHOLL R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SALLY SEMLAK R.N.

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 SPRUCE ST
VERONA WI
53593-1644
US

IV. Provider business mailing address

717 SPRUCE ST
VERONA WI
53593-1644
US

V. Phone/Fax

Practice location:
  • Phone: 608-576-9701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number59130-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number59130-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: