MEDICARE: MISS KATIE LYNN MORTIER KATIE MORTIER

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	163WP0200X	Pediatric Registered Nurse	149864-030	WI

General Provider Information

NPI Number	:	1942505300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KATIE LYNN MORTIER KATIE MORTIER

Provider Business Mailing Address
First Line	:	10421 W DARNEL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-2648
Country	:	US
Telephone Number	:	920-277-6146
Fax Number	:

Provider Business Practice Location Address
First Line	:	10421 W DARNEL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53224-2648
Country	:	US
Telephone Number	:	920-277-6146
Fax Number	:

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

Provider Enumeration Date	:	01/17/2011
Last Update Date	:	01/17/2011

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