Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 174N00000X | Lactation Consultant | ||
Y | 176B00000X | Midwife | 31-049 | WI |
NPI | 1316208044 |
---|---|
Provider Name | Stacy L Vandenput |
First Address | Green Bay, WI 54302-2640 |
Second Address | Green Bay, WI 54302-2640 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2012 |
Last Update Date | 12/10/2016 |