Provider Demographics
NPI:1073737078
Name:HABERER, MARK THOMAS (LPN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:HABERER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5310
Mailing Address - Country:US
Mailing Address - Phone:319-234-2893
Mailing Address - Fax:319-234-0354
Practice Address - Street 1:3251 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5310
Practice Address - Country:US
Practice Address - Phone:319-234-2893
Practice Address - Fax:319-234-0354
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP48603164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse