Basic Information
| Provider Information | |||||||||
| NPI: | 1003912429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLUS | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546601449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723961 | ||||||||
| FaxNumber: | 6083721109 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E VETERANS ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546603105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
| FaxNumber: | 6083721109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1016029 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.