ELLEN LOUISE BLANK MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN AND SURGEON

License Number

036108149

License Status

NOT RENEWED

Business

First Name

ELLEN

Middle

LOUISE

Last Name

BLANK

Suffix

Business Name

ELLEN LOUISE BLANK MD

Original Issue Date

11/13/2002

Effective Date

11/13/2002

Expiration Date

07/31/2005

City

MILWAUKEE

State

Zip

53211

County

WISCONSIN

Ever Disciplined

LastModifiedDate

10/09/2006