Provider Demographics
NPI:1730493149
Name:BELISLE, KATIE ARLENE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ARLENE
Last Name:BELISLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ARLENE
Other - Last Name:BERGSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4404 STATE ROAD 70
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-9251
Mailing Address - Country:US
Mailing Address - Phone:715-349-8554
Mailing Address - Fax:715-349-2559
Practice Address - Street 1:4404 STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-9251
Practice Address - Country:US
Practice Address - Phone:715-349-8554
Practice Address - Fax:715-349-2559
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIL68151-3164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse