Provider Demographics
NPI:1689814972
Name:MORTIMER, JOAN ELLEN (RN)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:ELLEN
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2140
Mailing Address - Country:US
Mailing Address - Phone:262-782-1269
Mailing Address - Fax:262-782-7997
Practice Address - Street 1:830 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2140
Practice Address - Country:US
Practice Address - Phone:262-782-1269
Practice Address - Fax:262-782-7997
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI118722-30163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health