1255398947 NPI number — MRS. SALLY RAE NIZIOL LPN

Table of content: MRS. SALLY RAE NIZIOL LPN (NPI 1255398947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255398947 NPI number — MRS. SALLY RAE NIZIOL LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIZIOL
Provider First Name:
SALLY
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
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:
1255398947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 FLORENCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRONWOOD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49938-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
190-693-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HIGHWAY 64
Provider Second Line Business Practice Location Address:
W6604
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
171-574-8091
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2006

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: 3747P1801X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38297500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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