Provider Demographics
NPI:1982623534
Name:JOHN H BRADLEY DEPTARTMENT OF VETERANS AFFAIRS OUTPATIENT CLINIC
Entity Type:Organization
Organization Name:JOHN H BRADLEY DEPTARTMENT OF VETERANS AFFAIRS OUTPATIENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WOELFEL
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:920-831-0070
Mailing Address - Street 1:7187 ANGELL RD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-9544
Mailing Address - Country:US
Mailing Address - Phone:920-836-1998
Mailing Address - Fax:
Practice Address - Street 1:10 TRI-PARKWAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-831-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1456029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty