Provider Demographics
NPI:1114674421
Name:GALL, DEBORAH LEE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:GALL
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:W64N438 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2333
Mailing Address - Country:US
Mailing Address - Phone:262-707-9142
Mailing Address - Fax:
Practice Address - Street 1:616 E CIRCLE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5926
Practice Address - Country:US
Practice Address - Phone:262-227-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315383164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty