Provider Demographics
NPI:1801955679
Name:DYLLA, MARTIN F (LPN)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:F
Last Name:DYLLA
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 1:12744 W PECK PL
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:WI
Mailing Address - Zip Code:53007-1808
Mailing Address - Country:US
Mailing Address - Phone:141-441-6550
Mailing Address - Fax:
Practice Address - Street 1:12744 W PECK PL
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:WI
Practice Address - Zip Code:53007-1808
Practice Address - Country:US
Practice Address - Phone:141-441-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28605-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse