Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1073994133 |
---|---|
Provider Name | Kim Tavener |
First Address | Green Bay, WI 54301-3234 |
Second Address | Green Bay, WI 54301-3234 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2015 |
Last Update Date | 15/06/2015 |