Basic Information
| Provider Information | |||||||||
| NPI: | 1922395334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WUELLNER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | H.A.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168832660 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 E STATE ST | ||||||||
| Address2: | SUITE 324 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611081978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152279380 | ||||||||
| FaxNumber: | 8152279387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 03/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | AS4088 | FL | N | Other Service Providers | Specialist | 237700000X | 3122 | IL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.