Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 019.032049 | IL |
NPI | 1114372422 |
---|---|
Provider Name | Dr. Katrine Andreasen |
First Address | Rockford, IL 61107-5904 |
Second Address | Rockford, IL 61107 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2016 |
Last Update Date | 14/08/2019 |