Provider Demographics
NPI:1063735512
Name:LANGE, ETHEL
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:LANGE
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 1:78 NEW HAMPSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-2320
Mailing Address - Country:US
Mailing Address - Phone:207-723-9320
Mailing Address - Fax:
Practice Address - Street 1:CMR 414 BOX 1116
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09173-0012
Practice Address - Country:US
Practice Address - Phone:314-466-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY415326-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse