Provider Demographics
NPI:1679171003
Name:BARREDO, MAE
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:
Last Name:BARREDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 FRANCES LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1165
Mailing Address - Country:US
Mailing Address - Phone:920-885-5808
Mailing Address - Fax:
Practice Address - Street 1:120 FRANCES LN
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1165
Practice Address - Country:US
Practice Address - Phone:920-885-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15469-40183500000X
WI15468-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist