Provider Demographics
NPI:1922395334
Name:WUELLNER, MICHAEL RYAN (HAS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:WUELLNER
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 VICTORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068
Mailing Address - Country:US
Mailing Address - Phone:816-883-2660
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:3600 E STATE ST
Practice Address - Street 2:SUITE 324
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1978
Practice Address - Country:US
Practice Address - Phone:815-227-9380
Practice Address - Fax:815-227-9387
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4088174400000X
IL3122237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No174400000XOther Service ProvidersSpecialist