Healthcare Provider Details

I. General information

NPI: 1063586329
Provider Name (Legal Business Name): MARY J EICHELBERGER APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 N 76TH ST
MILWAUKEE WI
53223-1003
US

IV. Provider business mailing address

9301 N 76TH ST
MILWAUKEE WI
53223-1003
US

V. Phone/Fax

Practice location:
  • Phone: 414-357-5233
  • Fax: 414-357-5406
Mailing address:
  • Phone: 414-357-5233
  • Fax: 414-357-5406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number88611-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: