MEDICARE: MRS. THERESA MARIE BLASKOWSKI RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	132025-030	WI
2	163W00000X	Registered Nurse	253454	OH

General Provider Information

NPI Number	:	1265689194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA MARIE BLASKOWSKI RN

Provider Business Mailing Address
First Line	:	5109 COUNTY HIGHWAY X
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54703-6835
Country	:	US
Telephone Number	:	715-874-4969
Fax Number	:

Provider Business Practice Location Address
First Line	:	5109 COUNTY HIGHWAY X
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54703-6835
Country	:	US
Telephone Number	:	715-874-4969
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2008
Last Update Date	:	08/21/2008

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