Basic Information
Provider Information | |||||||||
NPI: | 1457543217 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESPEARS | ||||||||
FirstName: | CATHY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOCOL | ||||||||
OtherFirstName: | CATHY | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 210 W CAPITOL DRIVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532121123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147276320 | ||||||||
FaxNumber: | 4147276321 | ||||||||
Practice Location | |||||||||
Address1: | 210 W CAPITOL DRIVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532121123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147276320 | ||||||||
FaxNumber: | 4147276321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2007 | ||||||||
LastUpdateDate: | 08/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 21384031 | WI | Y |   | Nursing Service Providers | Licensed Practical Nurse |   |
No ID Information.