=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780356477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY VANDERLOOP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2021
-----------------------------------------------------
Last Update Date | 09/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 E JOHNSON ST
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-8900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-266-4323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 E PIONEER RD APT 8
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-6531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-378-8780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 21134
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------