Provider Demographics
NPI:1043623192
Name:MOTT, EDITH JOYCE (LPN)
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:JOYCE
Last Name:MOTT
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 1:803 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3336
Mailing Address - Country:US
Mailing Address - Phone:715-581-3342
Mailing Address - Fax:
Practice Address - Street 1:803 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3336
Practice Address - Country:US
Practice Address - Phone:715-581-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315716-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse