Healthcare Provider Details

I. General information

NPI: 1124697768
Provider Name (Legal Business Name): MARY GRACE ELAINE COURCHANE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

700 S PARK ST
MADISON WI
53715-1830
US

V. Phone/Fax

Practice location:
  • Phone: 608-260-2900
  • Fax: 608-260-3442
Mailing address:
  • Phone: 608-260-2900
  • Fax: 608-260-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10440
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10440
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: