Healthcare Provider Details

I. General information

NPI: 1508291238
Provider Name (Legal Business Name): THERESE MARIE O'GRADY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESE MARIE ZEI RN

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W1007 VIOLET RD
GENOA CITY WI
53128-1666
US

IV. Provider business mailing address

PO BOX 939
PELL LAKE WI
53157-0939
US

V. Phone/Fax

Practice location:
  • Phone: 262-215-8747
  • Fax: 262-295-8338
Mailing address:
  • Phone: 262-215-8747
  • Fax: 262-295-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number86757-030
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.190108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: