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General NPI Number Information
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NPI Number | 1982252631
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Entity Type | Individual
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Provider Name | LORRIE ANN FORMELLA
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Gender | Female
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Dates
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Enumeration Date | 08/27/2019
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Last Update Date | 08/27/2019
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Provider Practice Location Address
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Address Line | 604 N RICHMOND ST
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City | APPLETON
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State | WI
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Zip | 54911-4659
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Country | US
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Telephone | 920-750-1845
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Fax |
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Provider Business Mailing Address
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Address Line | N7590 LOWER CLIFF RD
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City | SHERWOOD
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State | WI
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Zip | 54169-9704
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Country | US
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Telephone | 920-750-1845
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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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