Provider Demographics
NPI:1871852145
Name:HILLSTROM, TREVOR ADAM (LPN)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:ADAM
Last Name:HILLSTROM
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 S SAM ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH RANGE
Mailing Address - State:WI
Mailing Address - Zip Code:54874-8524
Mailing Address - Country:US
Mailing Address - Phone:218-390-1049
Mailing Address - Fax:
Practice Address - Street 1:4601 S SAM ANDERSON RD
Practice Address - Street 2:
Practice Address - City:SOUTH RANGE
Practice Address - State:WI
Practice Address - Zip Code:54874-8524
Practice Address - Country:US
Practice Address - Phone:218-390-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL050451-9164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse