MEDICARE: MARIAN QUIMIMANLES METTLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	173501-30	WI

General Provider Information

NPI Number	:	1912416850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAN QUIMIMANLES METTLE

Provider Business Mailing Address
First Line	:	1710 S 7TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3538
Country	:	US
Telephone Number	:	414-645-8383
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 S 7TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3538
Country	:	US
Telephone Number	:	414-645-8383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2017
Last Update Date	:	07/21/2022

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