Provider Demographics
NPI:1336698653
Name:COLLIGAN, GENEROSE L
Entity Type:Individual
Prefix:
First Name:GENEROSE
Middle Name:L
Last Name:COLLIGAN
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:N5754 COUNTY ROAD AA
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-5900
Mailing Address - Country:US
Mailing Address - Phone:920-622-4969
Mailing Address - Fax:
Practice Address - Street 1:N5754 COUNTY ROAD AA
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-5900
Practice Address - Country:US
Practice Address - Phone:920-622-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI318070164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse