Provider Demographics
NPI:1174812499
Name:KOLLER SHUMATE, ANNALIESE MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:ANNALIESE
Middle Name:MARIE
Last Name:KOLLER SHUMATE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:3RD FLOOR, DEPARTMENT OF PSYCHIATRY
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-8990
Mailing Address - Fax:
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:3RD FLOOR, DEPARTMENT OF PSYCHIATRY
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60433-21208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice