Healthcare Provider Details

I. General information

NPI: 1295094571
Provider Name (Legal Business Name): JULIE ANN THIEL BS PHARM, BCPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 NORTH DRIVE
WINNEBAGO WI
54985
US

IV. Provider business mailing address

1142 E RUSTIC RD
APPLETON WI
54911-8548
US

V. Phone/Fax

Practice location:
  • Phone: 920-235-4910
  • Fax:
Mailing address:
  • Phone: 920-915-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number12905
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: