Provider Demographics
NPI:1366289381
Name:PAVELKO, LUCY
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:PAVELKO
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:S67W14979 KOSO DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8954
Mailing Address - Country:US
Mailing Address - Phone:414-218-9884
Mailing Address - Fax:
Practice Address - Street 1:S67W14979 KOSO DR
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8954
Practice Address - Country:US
Practice Address - Phone:414-218-9884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86211061133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered