Healthcare Provider Details

I. General information

NPI: 1871517565
Provider Name (Legal Business Name): MARY THERESE LEVEILLE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY THERESE RYAN

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 ORCHARD ST
SEYMOUR WI
54165
US

IV. Provider business mailing address

1100 ORCHARD ST
SEYMOUR WI
54165
US

V. Phone/Fax

Practice location:
  • Phone: 920-833-5100
  • Fax: 920-833-5130
Mailing address:
  • Phone: 920-833-5100
  • Fax: 920-833-5130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number69002
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1456
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: