Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1417161381 |
---|---|
Provider Name | Mrs. Mary Ann Ostendorf |
First Address | Freeport, IL 61032-0655 |
Second Address | Freeport, IL 61032-0655 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 05/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
08932008 | BLUE CROSS BLUE SHIELD (01) |