Healthcare Provider Details

I. General information

NPI: 1710090246
Provider Name (Legal Business Name): MARY ROSALIE SEBASTIAN MS, APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 N DOWNER AVE SUITE 215
MILWAUKEE WI
53211-4253
US

IV. Provider business mailing address

2577 N DOWNER AVE SUITE 215
MILWAUKEE WI
53211-4253
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-9200
  • Fax:
Mailing address:
  • Phone: 414-964-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number73401-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: