Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 10999 | WI |
NPI | 1053832915 |
---|---|
Provider Name | Afi Assignon |
First Address | Middleton, WI 53562-5531 |
Second Address | Madison, WI 53704-4155 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2017 |
Last Update Date | 30/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10999-16 | STATE LICENS (01) | WI |