Provider Demographics
NPI:1306053624
Name:PATRICK, FLORA MAE (LPN)
Entity type:Individual
Prefix:
First Name:FLORA
Middle Name:MAE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4769 N 29 ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-442-1780
Mailing Address - Fax:
Practice Address - Street 1:2092 S 102TH
Practice Address - Street 2:APT 13 LUCINDA CORMWELL
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-549-6899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16831031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3997330Medicare ID - Type Unspecified