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General NPI Number Information
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NPI Number | 1477892412
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Entity Type | Individual
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Provider Name | STACEY M NELLEN-KOLZE
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Gender | Female
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Dates
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Enumeration Date | 02/12/2013
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Last Update Date | 02/12/2013
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Provider Practice Location Address
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Address Line | 2031 S WEBSTER AVE SUITE B
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City | GREEN BAY
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State | WI
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Zip | 54301-2257
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Country | US
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Telephone | 920-393-4912
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Fax | 920-393-4913
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Provider Business Mailing Address
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Address Line | 2031 S WEBSTER AVE SUITE B
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City | GREEN BAY
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State | WI
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Zip | 54301-2257
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Country | US
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Telephone | 920-393-4912
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Fax | 920-393-4913
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 456-1026562299-04
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License Number State | WI
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