Provider Demographics
NPI:1447521463
Name:POLIAK, MARY ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:POLIAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HELMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:N1073 MAPLE LEAF CT
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-9260
Mailing Address - Country:US
Mailing Address - Phone:920-841-0081
Mailing Address - Fax:
Practice Address - Street 1:1981 GREENGROVE ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-3921
Practice Address - Country:US
Practice Address - Phone:920-841-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77716-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health