Provider Demographics
NPI:1235303975
Name:BUSH, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 NTH 60 STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218
Mailing Address - Country:US
Mailing Address - Phone:414-212-8985
Mailing Address - Fax:414-212-8985
Practice Address - Street 1:5194 NTH TUETONIA AVE
Practice Address - Street 2:
Practice Address - City:MILW
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-212-8985
Practice Address - Fax:414-212-8985
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI374U00000X, 376G00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376G00000XNursing Service Related ProvidersNursing Home Administrator
No376K00000XNursing Service Related ProvidersNurse's Aide