Provider Demographics
NPI:1932758653
Name:BAKKUM, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BAKKUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E 7040 NYHUS ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTBY
Mailing Address - State:WI
Mailing Address - Zip Code:54667
Mailing Address - Country:US
Mailing Address - Phone:608-634-4342
Mailing Address - Fax:
Practice Address - Street 1:E 7040 NYHUS ROAD
Practice Address - Street 2:
Practice Address - City:WESTBY
Practice Address - State:WI
Practice Address - Zip Code:54667
Practice Address - Country:US
Practice Address - Phone:608-634-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider