Provider Demographics
NPI:1619315249
Name:GUTKOWSKI, SHIRLEY B
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:B
Last Name:GUTKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 SHADOW TRL
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-9335
Mailing Address - Country:US
Mailing Address - Phone:608-213-5865
Mailing Address - Fax:
Practice Address - Street 1:1266 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1918
Practice Address - Country:US
Practice Address - Phone:608-318-2800
Practice Address - Fax:608-318-1324
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3747016124Q00000X
174H00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist
No174H00000XOther Service ProvidersHealth Educator