Provider Demographics
NPI:1881173730
Name:FEDJE, ELIZABETH ROSE (LPN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:FEDJE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ROSE
Other - Last Name:WITHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54741-0106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S CENTER ST
Practice Address - Street 2:
Practice Address - City:FAIRCHILD
Practice Address - State:WI
Practice Address - Zip Code:54741-8280
Practice Address - Country:US
Practice Address - Phone:715-566-3754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315977-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse