Healthcare Provider Details

I. General information

NPI: 1649028887
Provider Name (Legal Business Name): MARCY ENGEBRETSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E VETERANS ST
TOMAH WI
54660-3105
US

IV. Provider business mailing address

N5329 CAMDEN CT
BLACK RIVER FALLS WI
54615-1337
US

V. Phone/Fax

Practice location:
  • Phone: 608-372-3971
  • Fax:
Mailing address:
  • Phone: 715-896-1192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15021
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number124582-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: