Provider Demographics
NPI:1366466310
Name:WEBER, MARCIA (LPN)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-3360
Mailing Address - Country:US
Mailing Address - Phone:920-766-5682
Mailing Address - Fax:
Practice Address - Street 1:10 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1658
Practice Address - Country:US
Practice Address - Phone:920-831-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10833-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10833-031OtherLICENSED PRACTICAL NURSE