Healthcare Provider Details

I. General information

NPI: 1104651652
Provider Name (Legal Business Name): MALES MAINVIEL NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 2ND ST
RICHLAND CENTER WI
53581-1914
US

IV. Provider business mailing address

24959 MORRIS VALLEY RD
RICHLAND CENTER WI
53581-6348
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6321
  • Fax:
Mailing address:
  • Phone: 608-639-0413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16165-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: