MEDICARE: AUDREY WILLEMS VAN DIJK 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	218829	WV

General Provider Information

NPI Number	:	1629543806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY WILLEMS VAN DIJK RN

Provider Business Mailing Address
First Line	:	3727 MAPLE GROVE DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1840
Country	:	US
Telephone Number	:	715-218-6884
Fax Number	:

Provider Business Practice Location Address
First Line	:	3727 MAPLE GROVE DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1840
Country	:	US
Telephone Number	:	715-218-6884
Fax Number	:

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

Provider Enumeration Date	:	10/04/2018
Last Update Date	:	10/04/2018

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