Provider Demographics
NPI:1336506047
Name:CROOK, MARY LEE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARY LEE
Middle Name:
Last Name:CROOK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY LEE
Other - Middle Name:
Other - Last Name:HIDDEMEN, MILLWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:826 LORINDA AVE
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-2021
Mailing Address - Country:US
Mailing Address - Phone:920-378-6872
Mailing Address - Fax:
Practice Address - Street 1:23 W SCOTT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2342
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:920-926-0060
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI319573-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse