Provider Demographics
NPI:1649580416
Name:WIERZBA, JAMAE SANDRA (LPN)
Entity Type:Individual
Prefix:
First Name:JAMAE
Middle Name:SANDRA
Last Name:WIERZBA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JAMAE
Other - Middle Name:SANDRA
Other - Last Name:GJERMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:279 COUNTY ROAD BB
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-9685
Mailing Address - Country:US
Mailing Address - Phone:608-333-1363
Mailing Address - Fax:
Practice Address - Street 1:279 COUNTY ROAD BB
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9685
Practice Address - Country:US
Practice Address - Phone:608-333-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312346-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse