Provider Demographics
NPI:1326616673
Name:WRUCK, HOLLY JANE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JANE
Last Name:WRUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JANE
Other - Last Name:WASECHEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 N CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 N CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2950
Practice Address - Country:US
Practice Address - Phone:920-427-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator