Provider Demographics
NPI:1770578106
Name:ELLEFSON PEIL, JUDY F
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:F
Last Name:ELLEFSON PEIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:F
Other - Last Name:ELLEFSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:842 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5788
Mailing Address - Country:US
Mailing Address - Phone:920-574-3622
Mailing Address - Fax:920-574-3661
Practice Address - Street 1:842 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5788
Practice Address - Country:US
Practice Address - Phone:920-574-3622
Practice Address - Fax:920-574-3661
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2122-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38795500Medicaid
WIT61848Medicare UPIN
WI38795500Medicaid