Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 35068734 | OH |
Y | 207N00000X | Dermatologist | 53126 | WI |
NPI | 1013022292 |
---|---|
Provider Name | Frances Stahl Ballo |
First Address | Manitowoc, WI 54220-4630 |
Second Address | Green Bay, WI 54313-6717 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2006 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1013022292 | (05) | WI |
171400017 | MEDICARE (01) | WI |
2040633 | (05) | OH |
53126-020 | STATE LICENSE (01) | WI |
BB4575126 | DEA (01) | WI |
G44752 | (02) | OH |