Basic Information
| Provider Information | |||||||||
| NPI: | 1891314050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZZETTA | ||||||||
| FirstName: | LUCILLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083738000 | ||||||||
| FaxNumber: | 6083738795 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083738000 | ||||||||
| FaxNumber: | 6083738795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 12065-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1891314050 | 05 | WI | MEDICAID |