Provider Demographics
NPI:1962674689
Name:POULIN, LANE ELLEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:LANE
Middle Name:ELLEN
Last Name:POULIN
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 1:44045 WHEATVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GAYS MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:54631
Mailing Address - Country:US
Mailing Address - Phone:608-872-2156
Mailing Address - Fax:
Practice Address - Street 1:44045 WHEATVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GAYS MILLS
Practice Address - State:WI
Practice Address - Zip Code:54631
Practice Address - Country:US
Practice Address - Phone:608-872-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32436031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35053100Medicaid