Provider Demographics
NPI:1851313852
Name:GRONKE, ANGELICA M (RD CD)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:M
Last Name:GRONKE
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 N MEADE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3454
Mailing Address - Country:US
Mailing Address - Phone:920-738-5359
Mailing Address - Fax:920-831-5093
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-738-5359
Practice Address - Fax:920-831-5093
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI155929133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000840220Medicare ID - Type Unspecified