Healthcare Provider Details

I. General information

NPI: 1235303975
Provider Name (Legal Business Name): MARY L BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5194 NTH TUETONIA AVE
MILW WI
53209
US

IV. Provider business mailing address

5875 NTH 60 STREET
MILWAUKEE WI
53218
US

V. Phone/Fax

Practice location:
  • Phone: 414-212-8985
  • Fax: 414-212-8985
Mailing address:
  • Phone: 414-212-8985
  • Fax: 414-212-8985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: