Provider Demographics
NPI:1417900044
Name:FARBER, PHYLLIS (LPN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:FARBER
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 1:1409 NEVADA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1856
Mailing Address - Country:US
Mailing Address - Phone:608-249-5716
Mailing Address - Fax:
Practice Address - Street 1:3181 CONSERVANCY ESTATES LN
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-9249
Practice Address - Country:US
Practice Address - Phone:608-837-7219
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6453031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38213400Medicaid