Provider Demographics
NPI:1548391196
Name:PAULY, VICKI L (LPN)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:PAULY
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 1:151 N UNIVERSITY DR UNIT 115
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2936
Mailing Address - Country:US
Mailing Address - Phone:262-224-3369
Mailing Address - Fax:
Practice Address - Street 1:151 N UNIVERSITY DR UNIT 115
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2936
Practice Address - Country:US
Practice Address - Phone:262-224-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35008900Medicaid