Provider Demographics
NPI:1871103341
Name:WACHHOLZ, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:WACHHOLZ
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 1:420 W BARAGA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4563
Mailing Address - Country:US
Mailing Address - Phone:224-535-1139
Mailing Address - Fax:
Practice Address - Street 1:600 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-1017
Practice Address - Country:US
Practice Address - Phone:906-401-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered