Provider Demographics
NPI:1386034734
Name:DAHL, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DAHL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 S BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1523
Mailing Address - Country:US
Mailing Address - Phone:920-591-1510
Mailing Address - Fax:
Practice Address - Street 1:352 S BROWN AVE
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1523
Practice Address - Country:US
Practice Address - Phone:920-591-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64020-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health