Provider Demographics
NPI:1669790242
Name:MASSOGLIA, PETER JAMES (LPN)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:MASSOGLIA
Suffix:
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 1:117 W NORRIE ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2430
Mailing Address - Country:US
Mailing Address - Phone:906-932-8091
Mailing Address - Fax:
Practice Address - Street 1:117 W NORRIE ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-2430
Practice Address - Country:US
Practice Address - Phone:906-932-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310628-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse