Provider Demographics
NPI:1700848553
Name:STATE PRIVATE DUTY NURSING
Entity Type:Organization
Organization Name:STATE PRIVATE DUTY NURSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVATE DUTY NURSING
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:608-372-6908
Mailing Address - Street 1:11136 ELDER RD
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-8089
Mailing Address - Country:US
Mailing Address - Phone:608-372-6908
Mailing Address - Fax:
Practice Address - Street 1:11136 ELDER RD
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-8089
Practice Address - Country:US
Practice Address - Phone:608-372-6908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty