1669572566 NPI number — MRS. MARGARET R MATTICE MSN, APNP-BC

Table of content: MRS. MARGARET R MATTICE MSN, APNP-BC (NPI 1669572566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669572566 NPI number — MRS. MARGARET R MATTICE MSN, APNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTICE
Provider First Name:
MARGARET
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, APNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669572566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
888 THACKERAY TRL 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONOMOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53066-4342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-354-3744
Provider Business Mailing Address Fax Number:
262-354-3748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 W MAIN AVE
Provider Second Line Business Practice Location Address:
STE. 205
Provider Business Practice Location Address City Name:
DE PERE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54115-1698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-336-6455
Provider Business Practice Location Address Fax Number:
920-336-6646
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  2749-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41268900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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