Provider Demographics
NPI:1720057243
Name:BLANK, ELAINE MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARIE
Last Name:BLANK
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 1:7410 BOTTING RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-9742
Mailing Address - Country:US
Mailing Address - Phone:126-268-1303
Mailing Address - Fax:
Practice Address - Street 1:7410 BOTTING RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-9742
Practice Address - Country:US
Practice Address - Phone:126-268-1303
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17951-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse