Provider Demographics
NPI:1710246020
Name:MIERENDORF, ELIZABETH J (CA, MAOM, ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:MIERENDORF
Suffix:
Gender:F
Credentials:CA, MAOM, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W WINGRA DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1942
Mailing Address - Country:US
Mailing Address - Phone:608-516-8949
Mailing Address - Fax:
Practice Address - Street 1:890 W WINGRA DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1942
Practice Address - Country:US
Practice Address - Phone:608-516-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI733-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist