Healthcare Provider Details

I. General information

NPI: 1295056828
Provider Name (Legal Business Name): MARY R C SEIDL CPNP-AC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY R COOPER CPNP-AC, RN

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3360
  • Fax: 414-266-3563
Mailing address:
  • Phone: 414-266-3360
  • Fax: 414-266-3563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 234011-1
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberCNP 4719
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number157162-30
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number9275
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: