Provider Demographics
NPI:1578724530
Name:BORLESKE, AMANDA JANSSEN
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JANSSEN
Last Name:BORLESKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:JANSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:732 FAIRVIEW TER
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1554
Mailing Address - Country:US
Mailing Address - Phone:608-698-8873
Mailing Address - Fax:
Practice Address - Street 1:732 FAIRVIEW TER
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1554
Practice Address - Country:US
Practice Address - Phone:608-698-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15221-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist