Provider Demographics
NPI:1336455294
Name:MOUZAKIS, AUDRIE ROSE (RN)
Entity Type:Individual
Prefix:MRS
First Name:AUDRIE
Middle Name:ROSE
Last Name:MOUZAKIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AUDRIE
Other - Middle Name:ROSE
Other - Last Name:SOBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 HUNTERS RIDGE DR
Mailing Address - Street 2:UNIT 63
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-2532
Mailing Address - Country:US
Mailing Address - Phone:262-215-9691
Mailing Address - Fax:
Practice Address - Street 1:1400 HUNTERS RIDGE DR
Practice Address - Street 2:UNIT 63
Practice Address - City:GENOA CITY
Practice Address - State:WI
Practice Address - Zip Code:53128-2532
Practice Address - Country:US
Practice Address - Phone:262-215-9691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-29
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172876-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse