Provider Demographics
NPI:1962677500
Name:FERNHOLZ, MARCIA JANE (BS)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:JANE
Last Name:FERNHOLZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1146
Mailing Address - Country:US
Mailing Address - Phone:262-636-9203
Mailing Address - Fax:262-636-9165
Practice Address - Street 1:730 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1146
Practice Address - Country:US
Practice Address - Phone:262-636-9203
Practice Address - Fax:262-636-9165
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41862300Medicaid