Healthcare Provider Details

I. General information

NPI: 1669860581
Provider Name (Legal Business Name): MARY KOWATCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STURGEON EDDY RD
WAUSAU WI
54403-6754
US

IV. Provider business mailing address

555 STURGEON EDDY RD
WAUSAU WI
54403-6754
US

V. Phone/Fax

Practice location:
  • Phone: 715-581-5589
  • Fax:
Mailing address:
  • Phone: 715-581-5589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number132233
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: