Basic Information
| Provider Information | |||||||||
| NPI: | 1073740841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKRIVANIE | ||||||||
| FirstName: | LOIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 WEST POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9204903845 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 WEST POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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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 | 163WP0808X | 63080-030 | WI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 63080-030 | 01 | WI | STATE OF WISCONSIN | OTHER |