Provider Demographics
NPI:1356822894
Name:GUNNINK, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:GUNNINK
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 1:459 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-0163
Mailing Address - Fax:920-929-3680
Practice Address - Street 1:459 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-0163
Practice Address - Fax:920-929-3680
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI843036171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator