Provider Demographics
NPI:1316133960
Name:BACKUS, TRISHA ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:TRISHA
Middle Name:ANN
Last Name:BACKUS
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 1:1118 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3002
Mailing Address - Country:US
Mailing Address - Phone:920-884-9981
Mailing Address - Fax:
Practice Address - Street 1:1118 DIVISION ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3002
Practice Address - Country:US
Practice Address - Phone:920-884-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149463030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35033000Medicaid