Provider Demographics
NPI:1144472663
Name:FITZGERALD, MARJORY MATILDA
Entity type:Individual
Prefix:MRS
First Name:MARJORY
Middle Name:MATILDA
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4935 EDGEWATER BEACH RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-9789
Mailing Address - Country:US
Mailing Address - Phone:920-866-9470
Mailing Address - Fax:
Practice Address - Street 1:4935 EDGEWATER BEACH RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-9789
Practice Address - Country:US
Practice Address - Phone:920-866-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41709-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse