Provider Demographics
NPI:1679171433
Name:LUNDGREN, ANNIE MAE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:MAE
Last Name:LUNDGREN
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 1:7110 FOREST GLEN DR APT F
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8033
Mailing Address - Country:US
Mailing Address - Phone:414-937-0454
Mailing Address - Fax:
Practice Address - Street 1:7110 FOREST GLEN DR APT F
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8033
Practice Address - Country:US
Practice Address - Phone:414-937-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker