1811930035 NPI number — MRS. MARIE T STAUDER RN, LAPN, CDE

Table of content: MRS. MARIE T STAUDER RN, LAPN, CDE (NPI 1811930035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811930035 NPI number — MRS. MARIE T STAUDER RN, LAPN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAUDER
Provider First Name:
MARIE
Provider Middle Name:
T
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, LAPN, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811930035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
241 W WEAVER RD
Provider Second Line Business Mailing Address:
SUITE 210 DMH WELLNESS CENTER
Provider Business Mailing Address City Name:
FORSYTH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62535-9799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-876-5366
Provider Business Mailing Address Fax Number:
217-876-5375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N EDWARD ST
Provider Second Line Business Practice Location Address:
DECATUR MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-876-8121
Provider Business Practice Location Address Fax Number:
217-876-2261
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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