Provider Demographics
NPI:1558936187
Name:YANG, MARY L (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:YANG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2357 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2357 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4708
Practice Address - Country:US
Practice Address - Phone:920-337-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI322277-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629282470OtherEMPLOYER NPI