Basic Information
| Provider Information | |||||||||
| NPI: | 1003262742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALLER | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5956 S KINGAN AVE APT 8 | ||||||||
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| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531103448 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 S 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147445370 | ||||||||
| FaxNumber: | 4147449052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 301751-31 | WI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.