Provider Demographics
NPI:1437801867
Name:ALLIE, MARY ELIZABETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:ALLIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:ROUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:407 COUNCIL ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1619
Mailing Address - Country:US
Mailing Address - Phone:920-723-7288
Mailing Address - Fax:
Practice Address - Street 1:407 COUNCIL ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1619
Practice Address - Country:US
Practice Address - Phone:920-723-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI307129164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse