Provider Demographics
NPI:1881926210
Name:RETZLAFF, MARJORIE PAULINE (RN)
Entity type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:PAULINE
Last Name:RETZLAFF
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3395 COUNTY ROAD I
Mailing Address - Street 2:
Mailing Address - City:CATAWBA
Mailing Address - State:WI
Mailing Address - Zip Code:54515-9415
Mailing Address - Country:US
Mailing Address - Phone:715-474-2264
Mailing Address - Fax:
Practice Address - Street 1:719 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2965
Practice Address - Country:US
Practice Address - Phone:715-675-9858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI145353-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42005000Medicaid