Provider Demographics
NPI:1689714396
Name:PACKARD, KATHLEEN LOUSIE (LPN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LOUSIE
Last Name:PACKARD
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 1:2780 TORBLEAU RD
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-9700
Mailing Address - Country:US
Mailing Address - Phone:608-825-3945
Mailing Address - Fax:
Practice Address - Street 1:2780 TORBLEAU RD
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-9700
Practice Address - Country:US
Practice Address - Phone:608-825-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7654-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42023300Medicaid
WI7654-031OtherSTATE LICENSE NUMBER