Provider Demographics
NPI:1881208882
Name:ILLIES, MARTHA JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JEAN
Last Name:ILLIES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JEAN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8496 SILVERVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4404
Mailing Address - Country:US
Mailing Address - Phone:414-339-9124
Mailing Address - Fax:
Practice Address - Street 1:8496 SILVERVIEW CT
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4404
Practice Address - Country:US
Practice Address - Phone:414-339-9124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI173850-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse