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General NPI Number Information
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NPI Number | 1699201053
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Entity Type | Individual
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Provider Name | MADELINE MITTLESTADT
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Gender | Female
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Dates
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Enumeration Date | 05/04/2017
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Last Update Date | 03/25/2021
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Provider Practice Location Address
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Address Line | 1029 MADISON ST LOWR UNIT
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City | WAUKESHA
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State | WI
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Zip | 53188-4331
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Country | US
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Telephone | 920-213-3417
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Fax |
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Provider Business Mailing Address
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Address Line | 1029 MADISON ST LOWR UNIT
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City | WAUKESHA
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State | WI
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Zip | 53188-4331
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Country | US
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Telephone | 920-213-3417
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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