Healthcare Provider Details

I. General information

NPI: 1407815186
Provider Name (Legal Business Name): MARY WESLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 N 78TH ST
MILWAUKEE WI
53218-5306
US

IV. Provider business mailing address

4522 N 78TH ST
MILWAUKEE WI
53218-5306
US

V. Phone/Fax

Practice location:
  • Phone: 414-536-0340
  • Fax: 414-536-0340
Mailing address:
  • Phone: 414-536-0340
  • Fax: 414-536-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: