MEDICARE: MRS. ELAINE MARIE BLANK 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	17951-031	WI

General Provider Information

NPI Number	:	1720057243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELAINE MARIE BLANK LPN

Provider Business Mailing Address
First Line	:	7410 BOTTING RD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-9742
Country	:	US
Telephone Number	:	126-268-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	7410 BOTTING RD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-9742
Country	:	US
Telephone Number	:	126-268-1303
Fax Number	:

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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