1114074499 NPI number — MS. JO NEL MARIE (CHRISTIANSON) PREY

Table of content: MS. JO NEL MARIE (CHRISTIANSON) PREY (NPI 1114074499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114074499 NPI number — MS. JO NEL MARIE (CHRISTIANSON) PREY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
(CHRISTIANSON) PREY
Provider First Name:
JO NEL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PREY
Provider Other First Name:
JO NEL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSE,LPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114074499
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:
845 HERITAGE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSHKOSH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54904-8009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-233-4464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2380 STATE ROAD 44
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
OSHKOSH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54904-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-230-2065
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007

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: 101YP2500X , with the licence number:  488-125 , 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)





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