Provider Demographics
NPI:1336890490
Name:SOETENGA, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:SOETENGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 GREAT BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-9108
Mailing Address - Country:US
Mailing Address - Phone:216-789-6107
Mailing Address - Fax:
Practice Address - Street 1:4106 GREAT BRIDGE DR
Practice Address - Street 2:
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-9108
Practice Address - Country:US
Practice Address - Phone:216-789-6107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8764-33207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine