Provider Demographics
NPI:1831438407
Name:HERBST, MARY LOU (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:HERBST
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 1:555 CONNOR CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1665
Mailing Address - Country:US
Mailing Address - Phone:920-342-7748
Mailing Address - Fax:
Practice Address - Street 1:555 CONNOR CT
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1665
Practice Address - Country:US
Practice Address - Phone:920-342-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315524-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse