Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 61517-21 | WI |
N | 207Q00000X | Family Doctor | OS015861 | PA |
N | 207Q00000X | Family Doctor | OT013624 | PA |
NPI | 1003127465 |
---|---|
Provider Name | Dr. Rachael E. Vanden Langenberg |
First Address | Green Bay, WI 54311-6830 |
Second Address | Green Bay, WI 54311-6830 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2010 |
Last Update Date | 06/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
61517-21 | STATE LICENSE (01) | WI |