Provider Demographics
NPI:1487843538
Name:DITTMANN, C JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:JEAN
Last Name:DITTMANN
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 1:208 OGDEN AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-9036
Mailing Address - Country:US
Mailing Address - Phone:608-676-6127
Mailing Address - Fax:
Practice Address - Street 1:208 OGDEN AVE
Practice Address - Street 2:APT 4
Practice Address - City:CLINTON
Practice Address - State:WI
Practice Address - Zip Code:53525-9036
Practice Address - Country:US
Practice Address - Phone:608-676-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
IL164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35043800Medicaid