Healthcare Provider Details

I. General information

NPI: 1164575163
Provider Name (Legal Business Name): ANGELA J BEBO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 TERRACE AVE
MARINETTE WI
54143-2711
US

IV. Provider business mailing address

3366 WIGGINS WAY
GREEN BAY WI
54311
US

V. Phone/Fax

Practice location:
  • Phone: 715-735-8916
  • Fax:
Mailing address:
  • Phone: 715-330-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: