{
"Npi": {
"NPI": "1477892412",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "NELLEN-KOLZE",
"FirstName": "STACEY",
"MiddleName": "M",
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2031 S WEBSTER AVE",
"SecondLineMailingAddress": "SUITE B",
"MailingAddressCityName": "GREEN BAY",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "54301-2257",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "920-393-4912",
"MailingAddressFaxNumber": "920-393-4913",
"FirstLinePracticeLocationAddress": "2031 S WEBSTER AVE",
"SecondLinePracticeLocationAddress": "SUITE B",
"PracticeLocationAddressCityName": "GREEN BAY",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "54301-2257",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "920-393-4912",
"PracticeLocationAddressFaxNumber": "920-393-4913",
"EnumerationDate": "02/12/2013",
"LastUpdateDate": "02/12/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "335E00000X",
"TaxonomyName": "Prosthetic/Orthotic Supplier",
"LicenseNumber": "456-1026562299-04",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}