MEDICARE: MRS. PEGGY ANN GONWA-MARQUARDT LPN

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	164W00000X	Licensed Practical Nurse	16243-31	WI

General Provider Information

NPI Number	:	1417230400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PEGGY ANN GONWA-MARQUARDT LPN

Provider Business Mailing Address
First Line	:	1320 SCHOENHAAR DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53090-5401
Country	:	US
Telephone Number	:	262-338-1536
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 SCHOENHAAR DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53090-5401
Country	:	US
Telephone Number	:	262-338-1536
Fax Number	:

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

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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