Provider Demographics
NPI:1326050923
Name:WROLSTAD, THERESA M (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:WROLSTAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:DANTINNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2845 GREENBRIER RD STE 230
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8250
Mailing Address - Fax:920-288-8255
Practice Address - Street 1:2845 GREENBRIER RD STE 230
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8250
Practice Address - Fax:920-288-8255
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI119101163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1062730001OtherDIAMOND ID
WI1062730003OtherDIAMOND ID
WI1062730002OtherDIAMOND ID