Provider Demographics
NPI:1194900159
Name:WALL, MARY LOUISE (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:WALL
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:W168N10737 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-3964
Mailing Address - Country:US
Mailing Address - Phone:262-251-0200
Mailing Address - Fax:
Practice Address - Street 1:W168N10737 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-3964
Practice Address - Country:US
Practice Address - Phone:262-251-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65759-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse