Healthcare Provider Details

I. General information

NPI: 1619046026
Provider Name (Legal Business Name): MANDI LYNNE MARONN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16985 W BLUEMOUND RD
BROOKFIELD WI
53005-5909
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-641-8400
  • Fax:
Mailing address:
  • Phone: 262-532-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM8812
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberM8812
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number48358
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: