Provider Demographics
NPI:1215906706
Name:JUDITH C. MANN RN INDEPENDENT NURSE LLC
Entity type:Organization
Organization Name:JUDITH C. MANN RN INDEPENDENT NURSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:920-623-3449
Mailing Address - Street 1:W987 HALL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-9509
Mailing Address - Country:US
Mailing Address - Phone:920-623-3449
Mailing Address - Fax:920-623-3742
Practice Address - Street 1:W987 HALL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-9509
Practice Address - Country:US
Practice Address - Phone:920-623-3449
Practice Address - Fax:920-623-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI78528-030313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40002800OtherPROVIDER # MEDICAID