Provider Demographics
NPI:1942592639
Name:THOMALLA, MARIE AGATHA (LPN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:AGATHA
Last Name:THOMALLA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CANABURY CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1502
Mailing Address - Country:US
Mailing Address - Phone:763-238-1979
Mailing Address - Fax:
Practice Address - Street 1:1810 4TH AVE APT 5
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-5141
Practice Address - Country:US
Practice Address - Phone:715-684-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 70522-4164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse