Provider Demographics
NPI:1144867102
Name:PURTELL, MILDRED MAURILLO (LPN)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:MAURILLO
Last Name:PURTELL
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 1:312 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6887
Mailing Address - Country:US
Mailing Address - Phone:989-600-7369
Mailing Address - Fax:
Practice Address - Street 1:203 DARTMOUTH DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4513
Practice Address - Country:US
Practice Address - Phone:989-839-2311
Practice Address - Fax:800-336-0596
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703101031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703101031Medicaid