Provider Demographics
NPI:1891022554
Name:BOTELLO, JOSE M JR (LPN)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:BOTELLO
Suffix:JR
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 1:128 DEER CREEK CT
Mailing Address - Street 2:APT. 5
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1188
Mailing Address - Country:US
Mailing Address - Phone:920-397-0152
Mailing Address - Fax:
Practice Address - Street 1:128 DEER CREEK CT
Practice Address - Street 2:APT. 5
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1188
Practice Address - Country:US
Practice Address - Phone:920-397-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306116-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse