Provider Demographics
NPI:1255398947
Name:NIZIOL, SALLY RAE (LPN)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:RAE
Last Name:NIZIOL
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 1:721 FLORENCE ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1417
Mailing Address - Country:US
Mailing Address - Phone:190-693-2500
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 64
Practice Address - Street 2:W6604
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451
Practice Address - Country:US
Practice Address - Phone:171-574-8091
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38297500Medicaid