Basic Information
| Provider Information | |||||||||
| NPI: | 1003011149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOSKOWIAK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3063 GLENDALE AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204341045 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | N6185 SCHOOL CREEK TRAIL | ||||||||
| Address2: | |||||||||
| City: | LUXEMBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208452128 | ||||||||
| FaxNumber: | 9208452128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 32072-031 | WI | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 38321000 | 05 | WI | MEDICAID |