Provider Demographics
NPI:1326679663
Name:DOSEDLA, ANDREA MARIA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIA
Last Name:DOSEDLA
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 1:1141 S 75TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3020
Mailing Address - Country:US
Mailing Address - Phone:262-210-7127
Mailing Address - Fax:
Practice Address - Street 1:N61W23044 HARRYS WAY
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3995
Practice Address - Country:US
Practice Address - Phone:414-566-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1682-39405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional