Provider Demographics
NPI:1780804955
Name:TABBERT, MARY LOUISE (RN, BSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:TABBERT
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W21429 BROWNS ADDITION LANE
Mailing Address - Street 2:
Mailing Address - City:GALESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54630
Mailing Address - Country:US
Mailing Address - Phone:608-397-5549
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST STE 100
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2378
Practice Address - Country:US
Practice Address - Phone:608-785-6267
Practice Address - Fax:608-785-6315
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57345-030163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health