Basic Information
| Provider Information | |||||||||
| NPI: | 1336506047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROOK | ||||||||
| FirstName: | MARY LEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIDDEMEN, MILLWOOD | ||||||||
| OtherFirstName: | MARY LEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 826 LORINDA AVE | ||||||||
| Address2: | |||||||||
| City: | OMRO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549632021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203786872 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23 W SCOTT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209260101 | ||||||||
| FaxNumber: | 9209260060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 01/26/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 319573-31 | WI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.