Provider Demographics
NPI:1558122648
Name:WIESE, GABRIELLE MARIE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:MARIE
Other - Last Name:MANTEUFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74 S MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4274
Mailing Address - Country:US
Mailing Address - Phone:920-924-5222
Mailing Address - Fax:
Practice Address - Street 1:74 S MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4274
Practice Address - Country:US
Practice Address - Phone:920-924-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator