Provider Demographics
NPI:1134127319
Name:KOHLRUSCH, THERESA (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOHLRUSCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN STREET EAST
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0308
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI858363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00496OtherMEDICARE GROUP
1027253OtherPREFERRED ONE
WI43826100Medicaid
500025737OtherPALMETTO GBA RR MEDICARE
WI43826100Medicaid