Healthcare Provider Details

I. General information

NPI: 1215906706
Provider Name (Legal Business Name): JUDITH C. MANN RN INDEPENDENT NURSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W987 HALL RD
COLUMBUS WI
53925-9509
US

IV. Provider business mailing address

W987 HALL RD
COLUMBUS WI
53925-9509
US

V. Phone/Fax

Practice location:
  • Phone: 920-623-3449
  • Fax: 920-623-3742
Mailing address:
  • Phone: 920-623-3449
  • Fax: 920-623-3742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number78528-030
License Number StateWI

VIII. Authorized Official

Name: MRS. JUDITH C. MANN
Title or Position: RN
Credential: RN BSN
Phone: 920-623-3449