Provider Demographics
NPI:1477892412
Name:NELLEN-KOLZE, STACEY M
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:NELLEN-KOLZE
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 1:2031 S WEBSTER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2257
Mailing Address - Country:US
Mailing Address - Phone:920-393-4912
Mailing Address - Fax:920-393-4913
Practice Address - Street 1:2031 S WEBSTER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2257
Practice Address - Country:US
Practice Address - Phone:920-393-4912
Practice Address - Fax:920-393-4913
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI456-1026562299-04335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier