Provider Demographics
NPI:1205009586
Name:BOTTERMAN, COLLEEN MARIE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:BOTTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1857
Mailing Address - Country:US
Mailing Address - Phone:920-410-2555
Mailing Address - Fax:
Practice Address - Street 1:500 CITY CTR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4830
Practice Address - Country:US
Practice Address - Phone:920-410-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI143446-030163W00000X
WI143446-30163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35046600Medicaid