Provider Information for 1639643802
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JULIE ANN PRUDOM LPC
Sex: Female
NPI: 1639643802
Last Updated: 2019-01-21
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1639643802 | ||||||||
| Enumeration Date | 2019-01-21 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 524 W WAYFARER CT APPLETON, WI 54913-6865 United States Phone: 920-851-4041 | Fax: | ||||||||
| Primary Practice Address | 524 W WAYFARER CT APPLETON, WI 54913-6865 United States Phone: 920-851-4041 | Fax: | ||||||||
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