Provider Demographics
NPI:1811280308
Name:FISK, MARY RUTH (LPN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:RUTH
Last Name:FISK
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 1:550 MAIN ST
Mailing Address - Street 2:230
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3271
Mailing Address - Country:US
Mailing Address - Phone:612-326-7600
Mailing Address - Fax:
Practice Address - Street 1:550 MAIN ST
Practice Address - Street 2:230
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3271
Practice Address - Country:US
Practice Address - Phone:612-326-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL41807164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse