Provider Demographics
NPI:1215184965
Name:DUCKWITZ, COLLEEN A
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:DUCKWITZ
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 1:4593 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2248
Mailing Address - Country:US
Mailing Address - Phone:608-835-0086
Mailing Address - Fax:
Practice Address - Street 1:4593 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-2248
Practice Address - Country:US
Practice Address - Phone:608-835-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59927-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35065800Medicaid