Provider Demographics
NPI:1306585559
Name:PAULSON, EMMA MARIE ISELIN
Entity type:Individual
Prefix:
First Name:EMMA MARIE
Middle Name:ISELIN
Last Name:PAULSON
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:W7810 STATE ROAD 21 STE B
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7702
Mailing Address - Country:US
Mailing Address - Phone:920-787-9561
Mailing Address - Fax:
Practice Address - Street 1:W7810 STATE ROAD 21 STE B
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7702
Practice Address - Country:US
Practice Address - Phone:920-787-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20405-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist