Basic Information
| Provider Information | |||||||||
| NPI: | 1417615600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEGATE | ||||||||
| FirstName: | JOLIE | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1128 COPRINUS DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543134210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204717214 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10800 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622414848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2021 | ||||||||
| LastUpdateDate: | 12/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3720-35 | WI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.