Healthcare Provider Details

I. General information

NPI: 1144864356
Provider Name (Legal Business Name): MARIE K DZIEWIT APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 920-725-4527
  • Fax: 920-729-2378
Mailing address:
  • Phone: 920-725-4527
  • Fax: 920-729-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9468-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: