Basic Information
| Provider Information | |||||||||
| NPI: | 1124482898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAHLBERG | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STROEHER | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1924 N 46TH ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981036810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065603085 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE # 222WP2 | ||||||||
| Address2: | UVM MEDICAL CENTER, DEPT OF INTERNAL MEDICINE | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2016 | ||||||||
| LastUpdateDate: | 06/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 060.0004558 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.