Provider Demographics
NPI:1417615600
Name:LEGATE, JOLIE DENISE (OD)
Entity Type:Individual
Prefix:DR
First Name:JOLIE
Middle Name:DENISE
Last Name:LEGATE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 COPRINUS DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-4210
Mailing Address - Country:US
Mailing Address - Phone:920-471-7214
Mailing Address - Fax:
Practice Address - Street 1:10800 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5007
Practice Address - Country:US
Practice Address - Phone:262-241-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-04
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3720-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist